20th Congress of the International Association of Rural Health and Medicine (IARM20)
Date October 10 (Wed) – October 12 (Fri), 2018
Venue TFT HALL (Tokyo Fashion Town Building), Tokyo, Japan
Congress President Shuzo Shintani (Director, JA Toride Medical Center)
TFT Hall Conference Program & Abstracts
Organized by International Association of Rural Health and Medicine (IARM)
Contents
Welcome Message from IARM20 Congress President ...... 1
Greetings from the President of IARM...... 2
Conference Information ...... 5
Access ...... 6
2018 IARM/JARM Congress Schedule ...... 8
Venue Map ...... 10
General Information...... 12
2018 Congress Schedule ...... 18
Abstracts...... 30
Advertisement Acknowledgements ...... 161
Welcome Message from IARM20 Congress President
Shuzo Shintani, MD President, 20th Congress of the International Association of rural health and medicine (IARM) President, the Japanese Association of Rural Medicine (JARM) Director, JA Toride Medical Center, Ibaraki, Japan
Dear colleagues, It is our great honor and pleasure to invite you to attend the 20th International Congress of the International Association of Rural Health and Medicine (IARM) to be jointly held with the 67th Annual Meeting of the Japanese Association of Rural Medicine on 10-12 October 2018, in Tokyo, Japan. The theme of the congress is “Challenges to community-based rural medicine in aging societies with declining productive populations”.
As you are aware, our congress every three years provides one of the most exciting and respected platforms by which we come together to share our discoveries and ideas. We learn from one another. We create new relationships. And our work is enriched by this exchange. We return to our countries and hospitals with a renewed sense of purpose and enthusiasm for our work.
This congress aims to promote valuable international exchange and further progress in the field of rural medicine, and to enhance international collaborations across the world. It will be a great and exciting time for physicians, scientists, nurses and the professionals of other related fields to present their most recent research achievements and ideas, and share the knowledge. The scientific program will cover topics of almost all the branches of rural medicine, reflecting the latest developments in fundamental and clinic research in rural medicine. It is in every scientific program, poster session, symposium, and keynote lecture that helps you understand the rural medicine more and perform your work better.
Attendees will benefit from meeting and interacting with participating international specialists for refreshing knowledge base, research as well as clinical skills, and from opportunities for establishing long-term international collaborations. The value of this congress, which you will feel in a handshake with old friends and new colleagues, will last for months and years to come. We ensure you that the congress will be an influential event. We hope to see you in Tokyo,
Sincerely yours, October 10, 2018
1 Greetings from the President of IARM
Prof. Dr. Hans-Joachim Hannich President, International Association of Rural Health and Medicine (IARM)
As president of IARM it is an immense pleasure for me to invite you to the 20th International Congress of the International Association and Rural Health and the 67th Annual Meeting of the Japanese Association of Rural Medicine. This Joint Congress takes place from the 10th till the 12 of October in Tokyo.
The focus of this international Congress on “Challenges to community-based rural medicine in aging societies with declining productive populations” is relevant for several countries all over the world. According to the 2015 Revision of the World Population Prospects of the United Nation Population Division, we have to expect a significant change in the rate of people with 65 years or older in the world countries. This is especially true for Japan where, by the year 2025, almost one in every five Japanese people will be at the age of 75 or over. In other countries, the aging of the societies is also remarkably progressing. When we look at Europe for instance, the population shift towards elderly people requires profound changes in the health system especially in Italy, France and Germany. Also in developing countries, the number of people older than 65 is gradually increasing. So, we can assume that addressing the issues of an aging society will be a common challenge worldwide.
As the generational change will mostly happen in rural areas, it is of particular importance to face its consequences for rural communities. Concepts of country-specific measures have to be developed taking into account the special situation of elderlies caused by rurality. The aim must be to establish a constant access to medical, nursing and social support on a low threshold level even in remote areas. The expansion of multiprofessional e-health oriented approaches can only be an example for steps leading into this direction. We, too, have to think about strengthening the competencies of families and of neighborhood in looking after elderly persons. This is not only true for rural, but also for urban settings. The search for solutions also includes the question of financing an elderly-oriented health care system, because someone has to pay the bill… At the latest at this point, it becomes clear that all parts of the society are involved to respond appropriately and humanly to the challenges of the aging society.
2 The 20th International Congress of IARM contributes to the world-wide discussion about generational change. Describing the current situation is the starting point for promoting future concepts of country-specific measures adapting to the challenge of elderly people. Highly relevant topics to be discussed are:
– the long-term effects of aging societies on the health care insurance systems – concepts for long-term care health insurance for elderly – country-specific preparations for elderly with dementia – country-specific views on the state of home health care for elderly
Experts from all over the world will present their experiences and research results on each of these topics. I also hope that the participants of this Congress will actively share their valuable views and contribute their findings to make this event an unique occasion for a fruitful and pioneering exchange of ideas.
My thanks go to the Japanese Association of Rural Medicine which is responsible for this important meeting. I congratulate the organizers for choosing the topic of aging societies as the main theme for the 20th International Congress of IARM and the 67th Annual Meeting of JARM and I wish them a grand success.
October 10, 2018
3
Conference Information
Theme: “Challenges to community-based rural medicine in aging societies withڦ declining productive populations”
Date: October 10 (Wed) – October 12 (Fri), 2018ڦ
(Venue㸸TFT HALL (Tokyo Fashion Town Buildingڦ 3-6-11 Ariake, Koto-ku, Tokyo, Japan 135-0063 TEL: +81-3-5530-1111 (Next to Tokyo Big Sight)
˛Official Language: English (We will have simultaneous interpreters in the all sessions including Q&A at the main venue A.)
,Congress President: Dr. Shuzo Shintani (Director, JA Toride Medical Centerڦ President of Japanese Association of Rural Medicine (JARM))
IARM20 Scientific Program Department: JA Toride Medical Center Ibaraki, Japanڦ
.Liaison Office: Procom International Co., Ltdڦ TFT Bldg. East Wing 9F, 3-6-11 Ariake Koto-ku Tokyo, 135-0063 Japan TEL: +81-3-5520-8821 FAX: +81-3-5520-8820 E-mail: [email protected]
Congress Website: http://procomu.jp/jarm-iarm2018/IARM20/
IARM Board Meetingڦ Date & Time: October 11 (Thu) 13:00 – 14:55 Place: Venue A
5 Access By Trainٹ
⋇Rinkai line Approx. 5-minutes walk from Kokusai-Tenjijo Station Osaki Sta. (JR) ← 13 minutes → Kokusai-Tenjijo Sta. ← 5 minutes → Shin-Kiba Sta.(JR,Subway) * Direct service at Osaki to JR Saikyo Line Kokusai-Tenjijo Sta. → JR Shibuya Sta. (approx. 20 minutes) → JR Shinjuku Sta. (approx. 25 minutes) → JR Ikebukuro Sta. (approx. 31 minutes)
⋈Yurikamome Approx. 1-minute walk from Kokusai-Tenjijo-Seimon Station Shimbashi Sta. (JR, Subways) ← 22 minutes → Kokusai-Tenjijo Seimon Sta.← 8 minutes → Toyosu Sta. (Subway)
By Busٹ
⋇Toei Bus 2-minutes walk from Ferry Pier Entrance or 1-minute walk from Kokusai-Tenjijo Seimon Sta. · East 16 bus line(via Toyosu Sta.) From Tokyo Sta. (Yaesu Exit) bound for Tokyo Big Sight ← approx. 34 minutes → Ferry Pier Entrance stop. · City 05 bus line (via Kachidoki Sta.) From Tokyo Sta. (Marunouchi South Exit) bound for Tokyo Big Sight ← approx. 34 minutes → Ferry Pier Entrance stop. · Gate 19 bus line(via Toyosu Sta.) From Monzennaka-cho bound for Tokyo Big Sight ← approx. 30 minutes → Tokyo Big Sight (3minutes walk)
⋈Airport Bus ( Limousine Bus , Keihin Kyuko Bus ) 5-minutes walk from Tokyo Big Sight Haneda Airport ← approx. 25 minutes → Tokyo Big Sight Narita Airport ← approx. 60 minutes → Tokyo Bay Ariake Washington Hotel ( 3 minutes walk ) One Way) Tokyo Big SightقTokyo City Air Terminal (TCAT) → approx. 20 minutes * Please chek in advance. Some bues only run while special events are held.
⋉Other Buses · Keihin Kyuko Bus (Express) From Yokohama Sta.(East Exit) ← approx. 50 minutes → Tokyo Big Sight. By Water-Bus
Water Busٹ Approx. 5-minutes walk from Ariake Terminal(Tokyo Big Sight). 25 minutes from Hinode Pier (approx. 7-minutes walk from JR Hamamatsucho Sta.) ͤIt suspends on Monday & Tuesday. (Holiday is operated.)
By Taxi & Carٹ From center of Tokyo From central Tokyo (Route No. 11 Daiba) → approx. 5 minutes from Daiba Exit From Yokohama/Haneda From Yokohama, Haneda, O-i (Wangan Route) → approx. 5 minutes from Rinkai Fukutoshin Exit From Chiba/Kasai From Chiba & Kasai (Wangan Route) → approx. 5 minutes from Ariake Exit
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7 2018 IARM/JARM Congress Schedule
2018 Venue A (TFT Hallࠉ500) October In Venue A, simultaneous translations are available for the Japanese audience in all English presentations
9 a.m. Joint Opening Ceremony International Association of Rural Health and Medicine (IARM) and Japanese Association of Rural Medicine (JARM) President lecture of JARM (Prof. Akira Hata) : 10 a.m. Current State and Future Prospects of Clinical Application of Genome Medical Research President lecture of IARM (Dr Shuzo Shintani) : 11 a.m. Home health care in patients with neurologic impairments in rural areas in Japan: (1) what is the long-term survival-determining factor ? (2) efficacy and ethics of artificial nutrition 12 a.m. (Lunch Break) 13 p.m. General Assembly of the Japanese Association of Rural Medicine (JARM) 10th 䐟㻌Prof. Peter Lundqvist & Dr. Kerstin Nilsson (Sweden) : 14 p.m. (Wed) Healthy and sustainable workplaces for older workers in agriculture - A Swedish perspective Dr. Dimitris Tsoukalas (Greece) : 15 p.m. 䐠㻌 Day 1 World aging population, chronic diseases and impact of modifiable-metabolic risk factors Special Lecture of JARM (Prof. Katsunori Kondo) : 16 p.m. Social Determinants of Health and Rural Medicine—Suggestions from Japan Gerontological Evaluation Study 䐡㻌Dr. René Thyrian (Germany) 䠖 17 p.m. Providing Dementia Care in a rural region in Germany – consequences of demographic change and concepts to encounter these 18 p.m. 䐢㻌Prof. NYGÅRD (Finland) : Aging and sustainable employment
䐣㻌Prof. Claudio Colosio (Italy) : 9 a.m. Workforce ageing an emerging challenge for Occupational Health and Safety and the Diagnosis and Prevention of Occupational Diseases 䐤㻌Prof. Petar Bulat (Serbia) : 10 a.m. Ageing Serbian rural population: defining the health care needs and searching for solutions Dr. Shengli Niu (ILO) : 11 a.m. 䐥㻌 Prevention of occupational risks and diseases in agriculture 12 a.m. (Lunch Break) 11th 13 p.m. Board Meeting and General Assembly (IARM) (Thu) 14 p.m. Prof. Dr. Hans-Joachim Hannich : President of the International Association of Rural Health and Medicine (IARM) 䐦 Dr. Joachim Breuer : President of the International Social Security Association (ISSA) 15 p.m. Day 2 Answers of the ISSA to challenges for social security in rural areas չ Dr Istvan Szilard (Hungary) : 16 p.m. The ageing population in Hungary – facts, challenges and endowers in the health and social policy Dr. Zoltan Katz (Hungary) : 17 p.m. 䐨 Ageing Roma ethnic minority population in Hungary – Challenges, realities, perspectives for the health and social care system 18 p.m. 19 p.m. 䚷䚷䚷䚷䚷䚷䚷䚷Social gathering party at the TOC (Tokyo wholesale center Ariake)
ջ Dr Kyeong Soo Lee (South Korea) : 9 a.m. Current situation and future prospects of South Korea health insurance systems including the long-term care health insurance for aging people ռ Dr Moo-Sik Lee (South Korea) : Preparation and Measures for Elderly with Dementia in Korea ; Focus on National Strategies and Action Plan against Dementia 䐫㻌Prof. Eunok Park (South Korea) : 12th Current state of home visit nursing care in South Korea (Fri) 12 a.m. (Lunch Break) Educational Lecture of JARM (Prof. Kiyohide Fushimi) : 13 p.m. Day 3 Utilization of healthcare big data to respond to a super aging society վ Prof. Nanako Tamiya (Japan) : 14 p.m. Overview of the post-war Japanese medical care system and prospects of medical and long-term care policies in the advent of ultra-aging society 䐭 Dr. Ashok Vikhe Patil (India) : 15 p.m. Global challenges to Rural Health and Medicine, with special reference to the Elderly in Rural areas 16 p.m. Joint Closing and Awards Ceremony of IARM and JARM
8 2018国際農村医学会・日本農村医学会 学術総会スケジュール
2018 Venue A (TFT ࣮࣍ࣝࠉ500) October 䛣䛾䝉䝑䝅䝵䞁䛾ⱥㄒⓎ⾲䛿䚸䛶ྠ㏻ヂ䠄㉁ᛂ⟅䜒䠅䛥䜜䜎䛩䛾䛷䚸ከ䛟䛾᪉䛾䛤ཧຍ䜢䛚ᚅ䛱䛧䛶䛚䜚䜎䛩 9 a.m. 㛤ᘧ㸦ྜྠ㸧 ᅜ㝿㎰ᮧ་Ꮫ㸦IARM㸧࣭᪥ᮏ㎰ᮧ་Ꮫ㸦JARM㸧
10 a.m. 㛗ㅮ₇㸦JARM㸧㸸⩚⏣ࠉ᫂㸦༓ⴥᏛᏛ㝔་Ꮫ◊✲㝔බ⾗⾨⏕Ꮫᩍᤵࠊ᪥ᮏ㎰ᮧ་Ꮫ⌮㛗㸧 ࢤࣀ࣒་Ꮫ◊✲ࡢ⮫ᗋᛂ⏝ࡢ⌧≧ᚋࡢᒎᮃ
㛗ㅮ₇㸦IARM㸧㸸᪂㇂࿘୕㸦Ⲉᇛ┴ཌ⏕㐃 JAࡾ࡛⥲ྜ་⒪ࢭࣥࢱ࣮㝔㛗ࠊ᪥ᮏ㎰ᮧ་Ꮫ⌮㛗㸧 11 a.m. ࠕ᪥ᮏࡢᆅᇦ་⒪࠾ࡅࡿ⚄⤒ᝈᝈ⪅ࡢᅾᏯࢣ㸸 㸦1㸧㛗ᮇࡢ⏕ᏑࢆỴᐃ࡙ࡅࡿᅉᏊࡣఱ㸽㸦2㸧ேᕤⓗᰤ㣴⟶⌮ࡢ᭷ຠᛶ⌮ᛶࡘ࠸࡚ࠖ 12 a.m. 䠄ఇ᠁䠅 13 p.m. ᪥ᮏ㎰ᮧ་Ꮫࠉ➨67ᅇ㏻ᖖ⥲࣭⾲ᙲᘧ 10th 14 p.m. 䐟 Prof. Peter Lundvst䠄ࢫ࢚࣮࢘ࢹࣥ㸧㸸Lund University, Division of Occupational and Environmental Medicine (Wed) ࠕ㎰ᴗᚑࡍࡿ㧗㱋ປാ⪅ࡢᗣⓗࡘᣢ⥆ྍ⬟࡞ປാ⎔ቃ㸸ࢫ࢙࣮࢘ࢹࣥ࠾ࡅࡿ⪃ᐹࠖ Day 1 15 p.m. 䐠 Dr. Dimitris Tsoukalas䠄ࢠࣜࢩ㸧㸸 President of the European Institute of Nutritional Medicine䠖E.I.Nu.M. ࠕୡ⏺ࡢேཱྀࡢ㧗㱋ࠊ៏ᛶᝈ࠾ࡼࡧಟṇྍ⬟࡞௦ㅰࣜࢫࢡᅉᏊࡢᙳ㡪ࠖ JARM 16 p.m. ≉ูㅮ₇㸦 㸧㸸㏆⸨ඞ๎ ༓ⴥᏛண㜵་Ꮫࢭࣥࢱ࣮ᩍᤵ㸧 ࠕᗣࡢ♫ⓗỴᐃせᅉ㎰ᮧ་Ꮫ - JAGESࡽࡢ♧၀ࠖ 17 p.m. 䐡 Dr. René Thyrian䠄ࢻࢶ㸧䠖Group Leader, German Center for Neurodegenerative Diseases (DZNE) ࠕࢻࢶࡢᆅᇦ࠾ࡅࡿㄆ▱ࢣࡢᥦ౪ࠉ̿ேཱྀᵓ㐀ࡢኚࡼࡿᙳ㡪ࡑࡢᑐ⟇̿ࠖ 18 p.m. 䐢 Prof. NYGÅRD䠄ࣇࣥࣛࣥࢻ㸧㸸Faculty of Social Sciences Health Sciences, University of Tampere ࠕ㧗㱋ᣢ⥆ྍ⬟࡞㞠⏝ࠖ
9 a.m. 䐣 Prof. Claudio Colosio䠄ࢱࣜ㸧㸸Department of Health Sciences of the University of Milan ࠕປാேཱྀࡢ㧗㱋㸸ປാ⾨⏕Ᏻࠊ⫋ᴗࡢデ᩿ண㜵ᑐࡍࡿ᪂ࡋ࠸ᣮᡓࠖ
10 a.m. 䐤 Prof. Petar Bulat䠄ࢭࣝࣅ㸧㸸University of Belgrade Faculty of Medicine ࠕ㧗㱋ࡍࡿࢭࣝࣅࡢᆅ᪉ఫẸ㸸ᚲせࡉࢀࡿ་⒪ࡑࡢゎỴἲࡢ᳨ウࠖ 11 a.m. 䐥 Dr. Shengli Niu (ILO) : Senior Specialist on Occupational Health, International Labour Office (ILO) ࠕ㎰ᴗ࠾ࡅࡿ⫋ᴗࡢࣜࢫࢡࡢண㜵ࠖ 12 a.m. 䠄ఇ᠁䠅 11th 13 p.m. ᅜ㝿㎰ᮧ་Ꮫ㸦IARM㸧࣭⌮/⥲ (Thu) 14 p.m. Prof. Hans-Joachim Hannich: ᅜ㝿㎰ᮧ་Ꮫ㸦IARM㸧࣭㛗 ո Dr. Joachim Breuer㸸 ᅜ㝿♫ಖ㞀༠㸦ISSA㸧䞉㛗 Day 2 15 p.m. ࠕ㎰ᮧᆅᇦ࠾ࡅࡿ♫ಖ㞀ࡢㄢ㢟ᑐࡍࡿISSA㸦ᅜ㝿♫ಖ㞀༠㸧ࡢᑐᛂ⟇ࠖ չ Dr Istvan Szilard㸦ࣁ࣮ࣥ࢞ࣜ㸧㸸Department of Operational Medicine, University of Pécs Medical School 16 p.m. ࠕࣁ࣮ࣥ࢞ࣜࡢ㧗㱋㸫ࡑࡢᐇែᗣ࣭♫ᨻ⟇࠾ࡅࡿㄢ㢟ࡸດຊ䠄endowers䠅ࠖ 17 p.m. պ Dr. Zoltan Katz㸦ࣁ࣮ࣥ࢞ࣜ㸧㸸 Assistant professor, University of Pécs, Medical School ࠕࣁ࣮ࣥ࢞ࣜࡢ㧗㱋ࡍࡿ࣐ࣟᑡᩘẸ᪘̿་⒪࠾ࡼࡧ♫ⓗࢣࢩࢫࢸ࣒ࡢㄢ㢟ࠊ⌧ᐇࠊᚋࡢᒎᮃࠖ 18 p.m. 19 p.m. ဨ᠓ぶ㸦TOCࢭࣥࢱ࣮᭷᫂㸸TFT࣮࣍ࣝࡽᚐṌ5ศ㸧
9 a.m. ջ Dr Kyeong Soo Lee 㡑ᅜ 㸸Department of Preventive Medicine, Yeungnam Univ. College of Medicine ࠕ㡑ᅜ࠾ࡅࡿᗣಖ㝤ࢩࢫࢸ࣒㸦㧗㱋⪅ᑐࡍࡿ㛗ᮇࡢㆤಖ㝤ࢩࢫࢸ࣒ࢆྵࡴ㸧ࡢ⌧ᅾᮍ᮶ࡢᒎᮃࡘ࠸࡚ࠖ ռ Dr Moo-Sik Lee 㡑ᅜ 㸸Department of Preventive Medicine, College of Medicine, Konyang University ࠕ㡑ᅜ࠾ࡅࡿ㧗㱋ㄆ▱ᝈ⪅ࡢᑐᛂᑐ⟇㸫ㄆ▱ᑐࡍࡿᅜᐙᡓ␎࠾ࡼࡧ⾜ືィ⏬ࠖ 12th 䐫 Prof. Eunok Park 㡑ᅜ 㸸College of Nursing, Jeju National University ࠕ㡑ᅜ䛻䛚䛡䜛ゼၥ┳ㆤ㸦home Visit Nursing Care㸧䛾⌧≧ࠖ (Fri) 12 a.m. 䠄ఇ᠁䠅 Day 3 JARM 13 p.m. ᩍ⫱ㅮ₇㸦 㸧㸸అぢΎ⚽㸦ᮾி་⛉ṑ⛉ᏛᏛ㝔ࠉ་⒪ᨻ⟇ሗᏛศ㔝ᩍᤵ㸧 ࠕ㉸㧗㱋♫ᑐᛂࡍࡿࡓࡵࡢ་⒪ㆤBig Dataࡢά⏝ࠖ
14 p.m. վ Prof. Nanako Tamiya㸦᪥ᮏ㸧㸸Department of Health Services Research, University of Tsukuba ࠕᡓᚋ᪥ᮏࡢ་⒪ไᗘࡢᴫせ࠾ࡼࡧ㉸㧗㱋♫ࡀ฿᮶ࡍࡿ᪥ᮏ࠾ࡅࡿ་⒪࣭㛗ᮇㆤᨻ⟇ࡢᒎᮃࠖ
15 p.m. տ Dr. Ashok Vikhe Patil㸦ࣥࢻ㸧㸸Immediate Past President of IARM ࠕᆅ᪉ࡢᗣ་⒪㛵ࡍࡿࢢ࣮ࣟࣂࣝㄢ㢟̿≉ᆅ᪉ࡢ㧗㱋⪅ࡘ࠸࡚ࠖ 16 p.m. 㛢ᘧࠊ⾲ᙲᘧࠊᮾிᐉゝ㸦ྜྠ㸧
9 Venue Map
West Wing 2F
Rinkai Line Kokusai-tenjijo Station
Drink East Wing 2F Service Venue To 1F To 1F Venue A G RinkaiRinkai LineLine (Kokusai-tenjijo(Kokusai-tenjijo Hall 500 Product Sales Station)Station)
PCPC CenterCenter
Venue B RegistrationRegistration Bridge: Directly To West Wing DeskDesk Shower Tree 35 Hall 300 connected to 2F (TFT Hall)
Poster ToTo TokyoTokyo BBigig SightSight YurikamomeYurikamome LineLine Exhibition (Kokusai-tenjijo(Kokusai-tenjijo Drink Service Station)Station)
Hall 1000 To 1F (To Tokyo Big Sight)
Restroom Elevator
Directly connected to Accessible facility Escalator Yurikamome Line Kokusai-tenjijo Station
10 TFT Building［West Wing 2F］
Venue B Poster Venue A Exhibition Hall 300 ElevatorElevator EElevatorlevator Drink Service Hall 500 RegistrationRegistration PCPC RinkaiRinkai LineLine DeskDesk CenterCenter Kokusai-tenjijoKokusai-tenjijo Entrance Lobby StationStation Hall 1000 EElevatorlevator EElevatorlevator Product Sales Drink Venue G Service Foyer Main Entrance
Directly connected to Cloak Reception and the meeting Luncheon Seminar Yurikamome Line place of Tour of Cancer Kokusai-tenjijo Station Tickets East Ariake Hospital Wing
TFT Building［East Wing 9F］
Venue D Room Room 901 902 Smoking Room 9-A Room
Robby
Room Venue Venue Venue 9－B C H I Room Room Room 904＋905 906 907 Elevator Elevator
ConnectedConnected toto WestWest WingWing VendingVending VendingVending (2F)(2F) MachineMachine Open Ceiling Space MachineMachine
ElevatorVenue Venue Room Elevator 910 TFT E F Building Room Office Room Room 9 C Room Room － 908 909 9-F 9－E
Drink Service
11 General Information
Registration 1. Place TFT Building West Wing 2F 2. Registration Hours Day 1: Wednesday, October 10 8:00 - 17:00 Day 2: Thursday, October 11 8:00 - 17:00 Day 3: Friday, October 12 8:00 - 14:00 3. On-site Registration Fee General: 56,000 JPY Accompany: 25,000 JPY Note: Please be prepared to pay in Japanese Yen. There will be no currency exchange. 4. Advance Online Registration Please bring the printout of your exchange ticket e-mail to the registration desk. The name card and the abstract booklet will be provided at the desk.
Welcome Party 1. Date Thursday, October 11 19:00 - 21:00 2. Venue TOC Ariake 20th Floor TOC West Tower 20F 3-5-7 Ariake, Koto-ku, Tokyo 135-0063 (A five-minute walk from the congress venue. You will be guided from the venue to the Welcome Party.) Note: Please use the West Tower Elevator, not the East Tower Elevator.
Access to TOC Ariake
TFT Building TFT Building East Wing West Wing Congress Venue Congress Venue
Panasonic Hotel Sunroute Ariake Center
Welcome Party Venue: TOC Ariake 20th Floor “West Gold 20Hall”
Rinkai Line Route 357
12 Cloakroom 1. Place TFT Building West Wing 2F (In front of Hall 1000) 2. Hours Day 1: Wednesday, October 10 8:00 - 19:00 Day 2: Thursday, October 11 8:00 - 18:00 Day 3: Friday, October 12 8:00 - 17:00 3. Note You are responsible for your valuables. Please pick up your luggage when you go to the Welcome Party. We cannot keep your luggage overnight.
Exhibition࣭Product Sales࣭Drink Service
1. Hours Day 1: Wednesday, October 10 9:00 - 19:00 Day 2: Thursday, October 11 9:00 - 18:00 Day 3: Friday, October 12 9:00 - 15:00 2. Location Exhibition: TFT Building West Wing 2F Hall 1000 Product Sales: TFT Building West Wing 2F in front of Hall 500 Drink Service: TFT Building West Wing 2F Hall 1000 and Foyer TFT Building West Wing 9F Room 9-F
Abstract Booklets Price: 1,000 JPY Each
Luncheon Seminar 1. Tickets will be distributed for the day in advance on a first-come, first-served basis. Those with a ticket may enter the Luncheon Seminar room first.
13 Others 1. Parking at the TFT Building is available but spaces are limited. We recommend using public transportation. Parking Spaces Floor Time Fee Height Limit
About 540 1F࣭B1F 7:00 - 23:00 250JPY/30minutes 1.5m - 2.1m (4 Handicapped)
2. The luncheon seminar (presentations in Japanese only) or restaurants near the venue are options for lunch. 3. Smoking is prohibited at the venue except in designated smoking areas. 4. There is no call service at the venue. 5. It is prohibited to take photos or record sessions at the venue, except by those who have obtained permission from the organizer and are wearing a “PRESS” name badge. 6. Please set your cell phone to silent mode or turn it off. 7. Tour of Cancer Ariake Hospital Date: October 11 and 12, 2018 (Thursday and Friday) Time: 14:00 – 15:00 Capacity: 30 people maximum each day (divided into 5 groups). Applications will be accepted on a first-come, first-served basis. Tour Details: Hospital press will guide you. (English will be available.) Fees: No Charge Application: Please sign up at the registration desk.
14 To Chairs and Speakers
Registration All chairpersons of the oral sessions are to register at the registration desk on the second floor of the West Wing of the TFT Building, which is the venue. Poster session speakers should check in at the reception desk at the entrance to the poster session room.
Oral Presentation Guidelines 1. Presentation Time All presentations should run within the time allotted by the session chairperson. Oral session speakers should adhere strictly to 6 minutes for presenting and 2 minutes for discussion (8 minutes total). The timekeeper will alert each speaker to the time remaining and end time of their presentation.
2. Presentation Equipment (Data and PCs) ࣭After registering, all oral session speakers should check in at the PC Center at least one hour prior to their presentation to submit their presentation data. ࣭Please do not bring your own Windows PC or Macintosh computer. ࣭All presentation materials should be formatted in Microsoft PowerPoint 2010, 2013 or 2016 for Windows PC. The Microsoft Windows operating system is the only system that will be used at the IARM conference. Please ensure your presentation is compatible with Windows. ࣭The slide size must be at a ratio of 4:3. In the PowerPoint 2013 initial setting, the size may be 16:9 when you click "Make a New Presentation.” However, if you open the slide at 16:9 with a monitor of 4:3, the top and bottom parts of the monitor will be blacked out. You are advised to prepare for a 4:3 ratio. ࣭You may submit presentation data in a USB memory stick or CD-R in the above format. ࣭Please check your presentation data for any viruses before arriving at the PC Center. ࣭We recommend that you also bring back-up data. ࣭Please use standard Windows fonts. ࣭A single projection screen without sound will be available for presentations. ࣭You will be permitted to use the monitor, keyboard, mouse, and laser pointer set on the presentation desk. ࣭Seats for the next speaker and next chairperson will be in each oral presentation room. Please be seated 15 minutes prior to your presentation. ࣭Name your presentation data using your name; e.g., “John Doe” ࣭When preparing your presentation, be mindful that if any of the contents could constitute a breach of personal information privacy, please obtain consent from the patient or his or her representative in advance. Presentations with personally identifiable information are strictly prohibited.
15 3. PC Center Location: 2F West Wing of TFT Building Date:
4. Conflict of Interest Conflict of interest (COI) disclosures should be announced before a presentation starts.
Poster Presentation Guidelines 㻞㻜䟛 㻣㻜䟛
1. Setup Time No. Title,Name(s),Affiliation(s) 㻞㻜䟛 9:00 - 12:00 (Thursday, October 11) 2. Q&A Time
Poster Presentation 16:00 - 17:00 (Thursday, October 11) 㻝㻤㻜䟛 Please be in front of your poster panel at the above designated time for Q&A. 3. Removal Time &2, 17:00 - 18:00 (Thursday, October 11) All posters should be taken down from the boards by the time stated above. The conference secretariat will not assume responsibility for the loss of posters left on the boards after the above-stated time period and/or after the conference is over. 4. Each speaker should exhibit a top banner 70 cm wide by 20 cm tall that shows the title, name(s) and affiliation(s) of the presenter on the right side of the poster number sheet at the upper-left corner of the poster board. (See figure above.) The size of space below the top banner of the poster should not be more than 90 cm wide or 180 cm tall. 5. Any conflict of interest (COI) should be noted on the poster. 6. Push pins will be available in the Poster Room.
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2018 Congress Schedule
Venue A㸦ሙ㸧TFT Hall 500 Day 1: October 10㸦Wed.㸧Ꮫ 1 ᪥┠㸸10 ᭶ 10 ᪥㸦Ỉ㸧 In Venue A, simultaneous translations are available for the Japanese audience in all English presentations. නͺɼસͱಋ࣎௪༃ʤ࣯ٛԢʥ͠ΗΉͤͲɼޢιρεϥϱӵ͞ ଡ͚๏͟ࢂՅΝ͕ଶͬ͢ͱ͕ΕΉͤ
9:00~9:55 㛤ᘧ㸦ྜྠ㸧 Opening Ceremony (Joint)
10:00~10:55➨67 ᅇ᪥ᮏ㎰ᮧ་ᏛᏛ⾡⥲㸦㛗ㅮ₇㸧 President lecture of JARM ʰࢤࣀ࣒་Ꮫ◊✲ࡢ⮫ᗋᛂ⏝ࡢ⌧≧ᚋࡢᒎᮃࠖ ʰCurrent State and Future Prospects of Clinical Application of Genome Medical Researchࠖ दʥگՌʀӶਫ਼ָ/ޮ़Ӷਫ਼ָߪ࠴ڂָָӅҫָݜځᗙ㛗ʁ㟷ᮌ୍㞝ʤེ Chairman: Prof. Kazuo Aoki, Public Health and Hygiene, Faculty of Medicine, University of the Ryukyus दɼೖຌଞҫָճ෯ཀྵࣆௗʥگӅޮ़Ӷਫ਼ָڂʁ⩚⏣ ᫂ʤએཁָָӅҫָݜ⪅₇ Speaker: Prof. Akira Hata, Dept. of Public Health, Chiba University Graduate School of Medicine
11:00~12:00 President Lecture (20th Congress of the International Association of Rural Health and Medicine (IARM) ʰHome health care in patients with neurologic impairments in rural areas in Japan: (1) what is the long-term survival-determining factor ? (2) Efficacy and ethics of artificial nutrition in the home health careʱ ʰ᪥ᮏࡢᆅᇦ་⒪࠾ࡅࡿ⚄⤒ᝈᝈ⪅ࡢᅾᏯࢣ㸸㸦1㸧㛗ᮇࡢ⏕ᏑࢆỴᐃ࡙ࡅࡿᅉᏊࡣఱ㸽 㸦2㸧ேᕤⓗᰤ㣴⟶⌮ࡢ᭷ຠᛶ⌮ᛶࡘ࠸࡚ʱ Chairman: Dr. Tomihiro HayakawaʤઔദʥDirector, Asuke Hospital, Aichi, JapanʤѬஎ ݟਫ਼࿊ ଏঁබӅӅௗʥ Speaker: Dr. Shuzo Shintaniʤ୫बࢀʥDirector, JA Toride Medical Center, President of the Japanese Association of Rural Medicine (JARM), JapanʤἜݟਫ਼࿊ JA ͳΕͲ૱ҫྏι ϱνʖӅௗɼೖຌଞҫָճཀྵࣆௗʥ
12:00~13:00 Lunch Break㸦ఇ᠁㸧
13:00~13:55 ᪥ᮏ㎰ᮧ་Ꮫ➨ 67 ᅇ㏻ᖖ⥲࣭⾲ᙲᘧ General Meeting of the Japanese Association of Rural Medicine (JARM)
14:00~14:55 Keynote LectureʁIARM ձ 㸦Sweden ࢫ࢚࣮࢘ࢹࣥ ʰHealthy and sustainable workplaces for older workers in agriculture - A Swedish perspectiveʱ ʰ㎰ᴗᚑࡍࡿ㧗㱋ປാ⪅ࡢᗣⓗࡘᣢ⥆ྍ⬟࡞ປാ⎔ቃ㸸ࢫ࢙࣮࢘ࢹࣥ࠾ࡅࡿ⪃ᐹʱ Chairman: Prof. Kuninori ShiwakuʤԚݓʥSpecially-appointed professor of Shimane University, Faculty of Medicine, Shimane, Japanʤౣָࠞҫָ෨ दʥگಝ Speaker: Prof. Peter Lundqvist 2, Dr. Kerstin Nilsson 1, 2 1 Lund University, Division of Occupational and Environmental Medicine, Lund, Sweden, 2 Swedish University of Agricultural Sciences, Department of Work Science, Business Economic & Environmental Psychology, Alnarp, Sweden
18 15:00~15:55 Keynote Lectureʁ IARM ղ 㸦Greece ࢠࣜࢩ㸧 ʰWorld aging population, chronic diseases and impact of modifiable-metabolic risk factorsʱ ʰୡ⏺ࡢேཱྀࡢ㧗㱋ࠊ៏ᛶᝈ࠾ࡼࡧಟṇྍ⬟࡞௦ㅰࣜࢫࢡᅉᏊࡢᙳ㡪ʱ Chairman: Dr. Masanobu Tatsumiʤཱིਐ৶ʥThe association of preventive medicine of ฯ݊ࢩԋ෨ௗʥۂճ ࢊڢघݟ༩ҫָآIwate Prefecture, Iwate, Japanʤ Speaker: Dr. Dimitris Tsoukalas (President of the European Institute of Nutritional Medicine: E.I.Nu.M.)
16:00~16:55 ➨ 67 ᅇ᪥ᮏ㎰ᮧ་ᏛᏛ⾡⥲㸦≉ูㅮ₇㸧 Special Lecture of JARM ࠕᗣࡢ♫ⓗỴᐃせᅉ㎰ᮧ་Ꮫ- JAGES ࡽࡢ♧၀ࠖ ࠕSocial Determinants of Health and Rural Medicine—Suggestions from Japan Gerontological Evaluation Studyࠖ दʥگӅޮ़Ӷਫ਼ָڂᗙ㛗ʁ⩚⏣ ᫂ʤએཁָָӅҫָݜ Chairman: Prof. Akira Hata, Dept. of Public Health, Chiba University Graduate School of Medicine ιϱνʖ೧ָʀऀճՌڂद/ࠅཱིௗथҫྏݜگʁ㏆⸨ඞ๎ʤએཁָ༩ҫָιϱνʖ⪅₇ ෨ௗʥڂιϱνʖ೧ָՃݜڂݜָ Speaker: Prof. Katsunori Kondo, Center of Preventive Medical Sciences, Chiba University
17:00~17:55 Keynote LectureʁIARM ճ㸦Germany ࢻࢶ㸧 ʰProviding Dementia Care in a rural region in Germany – consequences of demographic change and concepts to encounter theseʱ ʰࢻࢶࡢᆅᇦ࠾ࡅࡿㄆ▱ࢣࡢᥦ౪ ̿ேཱྀᵓ㐀ࡢኚࡼࡿᙳ㡪ࡑࡢᑐ⟇̿ʱ Chairman: Dr. Hiroyuki Tomimitsuʤᕟ߄೯ʥVice Director, JA Toride Medical Center, Ibaraki, JapanʤἜݟਫ਼࿊ JA ͳΕͲ૱ҫྏιϱνʖ෯Ӆௗʥ Speaker: Dr. René Thyrian (Group Leader, German Center for Neurodegenerative Diseases (DZNE), DZNE Rostock/ Greifswald, Germany)
18:00~19:00 Keynote LectureʁIARM մ㸦Finland ࣇࣥࣛࣥࢻ㸧 ʰAging and sustainable employmentʱ ʰ㧗㱋ᣢ⥆ྍ⬟࡞㞠⏝ʱ Chairman: Dr. Yoshito IesakaʤՊࡖٝਕʥTuchiura Kyodo General Hospital, Ibaraki, Japan ಋබӅʥڢʤἜݟਫ਼࿊ ౖӞ Speaker: Prof. Clas-Håkan Nygård (Faculty of Social Sciences Health Sciences, University of Tampere, Finland)
19 Venue A㸦ሙ㸧TFT Hall 500 Day 2: October 11㸦Thu.㸧Ꮫ 2 ᪥┠㸸10 ᭶ 11 ᪥㸦ᮌ㸧 In Venue A, simultaneous translations are available for the Japanese audience in all English presentations. නɼસͱಋ࣎௪༃ʤ࣯ٛԢʥ͠ΗΉͤͲɼޢιρεϥϱӵ͞ ଡ͚๏͟ࢂՅΝ͕ଶͬ͢ͱ͕ΕΉͤ
9:00~9:55 Keynote Lectureʁյ㸦Italy ࢱࣜ㸧 ʰWorkforce ageing an emerging challenge for Occupational Health and Safety and the Diagnosis and Prevention of Occupational Diseasesʱ ʰປാேཱྀࡢ㧗㱋㸸ປാ⾨⏕Ᏻࠊ⫋ᴗࡢデ᩿ண㜵ᑐࡍࡿ᪂ࡋ࠸ᣮᡓʱ Chairman: Dr. Takeshi Momotsuʤඨ ݊ʥHonorary Director, Sado General Hospital, ݟਫ਼࿊ ࠦో૱බӅ໌༬Ӆௗʥ׃Niigata, Japanʤ Speaker: Prof. Claudio Colosio (Department of Health Sciences of the University of Milan, and International Centre for Rural Health of the S. Paolo Hospital of Milano, Italy)
10:00~10:55 Keynote Lectureʁն㸦Serbia ࢭࣝࣅ㸧 ࠕAgeing Serbian rural population: defining the health care needs and searching for solutionsʱ ʰ㧗㱋ࡍࡿࢭࣝࣅࡢᆅ᪉ఫẸ㸸ᚲせࡉࢀࡿ་⒪ࡑࡢゎỴἲࡢ᳨ウʱ Chairman: Dr. Naohito YamamotoʤࢃຌਕʥDirector, Kainan Hospital, Aichi, JapanʤѬஎ ݟਫ਼࿊ քೈබӅӅௗʥ Speaker: Prof. Petar Bulat (University of Belgrade Faculty of Medicine & Serbian Institute of Occupational Health, Belgrade Serbia)
11:00~12:00 Keynote Lectureʁշ㸦ILO, Switzerland ᅜ㝿ປാᶵ㛵ࠊࢫࢫ㸧 ʰPrevention of occupational risks and diseases in agricultureʱ ʰ㎰ᴗ࠾ࡅࡿ⫋ᴗࡢࣜࢫࢡࡢண㜵ʱ Chairman: Dr. Satoshi InabaʤҶཁ ʥEngaru Kousei Hospital, Hokkaido, Japanʤքಕ ਫ਼࿊ ԗܲਫ਼බӅʥ Speaker: Dr. Shengli Niu (Senior Specialist on Occupational Health, International Labour (Organizationʤࠅࡏ࿓ಉؽؖ ILOʥ, Geneva, Switzerland
12:00~13:00 Lunch break㸦ఇ᠁㸧
13:00~14:55 Board Meeting & General Assembly of the International Association of rural health and medicine (IARM) ᅜ㝿㎰ᮧ་Ꮫࠊ⌮࣭⥲ Prof. Dr. Hans-Joachim Hannich, President of the International Association of Rural Health and Medicine (IARM), University of Greifswald, Institute for Medical Psychology, GERMANY ᮏᏛࡣࠊ㎰ᮧ་Ꮫ࡞ࡽࡧᆅᇦ་⒪/ᆅᇦಖ⫋ᴗࡋ࡚ᦠࢃࡿேࡓࡕࡢ⮬⊂❧ࡢ⤌⧊࡛ ࠶ࡾࠊWHOࠊILOࠊFAOࠊUNESCO ࡸ㛵㐃 NGO ࡞༠ຊࡋ࡞ࡀࡽࠕ21 ୡ⣖ࡍ࡚ࡢே ᗣࢆࠖࡍࡿ WHO ࡀᥖࡆࡿ┠ⓗࢆᨭᣢࡋ࡚࠸ࡲࡍࠋ
20 15:00~15:55 Keynote Lectureʁո International Social Security Association (ISSA) ᅜ㝿♫ಖ㞀༠ ʰAnswers of the ISSA to challenges for social security in rural areasʱ ʰ㎰ᮧᆅᇦ࠾ࡅࡿ♫ಖ㞀ࡢㄢ㢟ᑐࡍࡿ ISSA㸦ᅜ㝿♫ಖ㞀༠㸧ࡢᑐᛂ⟇ʱ Chairman: Dr. Kohji Suzukiʤྵ߃࢚ʥJA Toride Medical Center, Ibaraki, JapanʤἜݟ ਫ਼࿊ JA ͳΕͲ૱ҫྏιϱνʖʥ Speaker: Dr. Joachim Breuer, President of the International Social Security Association (ISSA), German Social Accident Insurance (DGUV), Berlin, Germany
16:00~16:55 Keynote Lectureʁչ㸦Hungary ࣁ࣮ࣥ࢞ࣜ㸧 ʰThe ageing population in Hungary – facts, challenges and endowers in the health and social policyʱ ʰࣁ࣮ࣥ࢞ࣜࡢ㧗㱋㸫ࡑࡢᐇែᗣ࣭♫ᨻ⟇࠾ࡅࡿㄢ㢟ࡸດຊ㸦endowers㸧ʱ Chairman: Dr. Satoshi Izawaʤґᖔ ෆʥDirector, Saku General Hospital, Nagano, Japan බӅ౹ׇӅௗʥ૱ٳ㸦㛗㔝┴ཌ⏕㐃ࠦ Speaker: Prof. Istvan Szilard (Department of Operational Medicine, University of Pécs Medical School, Hungary)
17:00~18:00 Keynote Lectureʁպ㸦Hungary ࣁ࣮ࣥ࢞ࣜ㸧 ʰAgeing Roma ethnic minority population in Hungary – Challenges, realities, perspectives for the health and social care systemʱ ʰࣁ࣮ࣥ࢞ࣜࡢ㧗㱋ࡍࡿ࣐ࣟᑡᩘẸ᪘̿་⒪࠾ࡼࡧ♫ⓗࢣࢩࢫࢸ࣒ࡢㄢ㢟ࠊ⌧ᐇࠊᚋࡢᒎᮃʱ ,Chairman: Dr. Kazuo SumimotoʤेݫҲʥDirector, Yoshida General Hospital, Hiroshima බӅӅௗʥ૱٤ీ Japanʤ߁ౣݟਫ਼࿊ Speaker: Dr. Zoltan Katz (Department of Operational Medicine – WHO Collaborating Centre, University of Pecs Medical School, Hungary)
19:00~21:00 ဨ᠓ぶ㸦TOC ࣅࣝ㸧 Social gathering party at the TOC (Tokyo wholesale center)
21 Venue A㸦ሙ㸧TFT Hall 500 Day 3: October 12㸦Fri.㸧Ꮫ 3 ᪥┠㸸10 ᭶ 12 ᪥㸦㔠㸧 In Venue A, simultaneous translations are available for the Japanese audience in all English presentations. නɼસͱಋ࣎௪༃ʤ࣯ٛԢʥ͠ΗΉͤͲɼޢιρεϥϱӵ͞ ଡ͚๏͟ࢂՅΝ͕ଶͬ͢ͱ͏Ήͤ
9:00~12:00 Symposium for the future prospects in progressive aging societies in South Korea 㸦South Korea 㡑ᅜ㸧ࢩ࣏ࣥࢪ࣒࢘㸸㡑ᅜ࠾࠸࡚㐍⾜ࡍࡿ㧗㱋ࡢ୰࡛ᑗ᮶ࡢᒎᮃ Chairman: (1) Dr. Yasuhiro Togawaʤॉઔ߃߄ʥDirector, Kamitsuga General Hospital, Tochigi, Japanʤծਫ਼࿊ ծ૱බӅӅௗʥ Mr. Eiji OouraʤӞӭ࣏ʥKouseiren of Toyama Prefecture, Toyama, Japanʤࢃݟਫ਼࿊ ݊߃ෳࢳ՟݊ (2) ߃ෳࢳΠχώδʖʥ
ʰCurrent situation and future prospects of South Korea health insurance systems including the long-term care health insurance for aging peopleʱ ఴʱޛฯݧΝ݊߃ฯݧౕݳয়ͳࠕޤʰؘࠅ߶ྺंͪΌղ Keynote SpeakerջʁProf. Kyeong Soo Lee (Vice-president of IARM, Department of Preventive Medicine & Public Health, Yeungnam Univ. College of Medicine, Daegu, Republic of Korea)
ᇷPreparation and Measures for Elderly with Dementia in Korea ; Focus on National Strategies and Action Plan against Dementiaᇸ ʰ㡑ᅜ࠾ࡅࡿ㧗㱋ㄆ▱ᝈ⪅ࡢᑐᛂᑐ⟇㸫ㄆ▱ᑐࡍࡿᅜᐙᡓ␎࠾ࡼࡧ⾜ືィ⏬ʱ Keynote SpeakerռʁMoo-Sik Lee MD, PhD (Department of Preventive Medicine, College of Medicine, Konyang University, Republic of Korea)
ʰCurrent State of Home Visit Nursing Care in South Koreaʱ ʰ㡑ᅜ࠾ࡅࡿゼၥ┳ㆤ㸦home Visit Nursing Care㸧ࡢ⌧≧ʱ Keynote SpeakerսʁProf. Eunok Park (College of Nursing, Jeju National University, Republic of Korea)
12:00~13:00 Lunch break㸦ఇ᠁㸧
13:00~13:55 ➨ 67 ᅇ᪥ᮏ㎰ᮧ་ᏛᏛ⾡⥲㸦ᩍ⫱ㅮ₇㸧Educational Lecture of JARM ࠕ㉸㧗㱋♫ᑐᛂࡍࡿࡓࡵࡢ་⒪ㆤ Big Data ࡢά⏝ࠖ ࠕUtilization of healthcare big data to respond to a super aging societyࠖ ᗙ㛗ʁ᪂㇂࿘୕ʤἜݟਫ਼࿊ JA ͳΕͲ૱ҫྏιϱνʖӅௗɼೖຌଞҫָճཀྵࣆௗʥ Chairman: Dr. Shuzo Shintani, Director, JA Toride Medical Center, President of the Japanese Association of Rural Medicine (JARM), Japan ₇⪅ʁఅぢΎ⚽㸦ᮾி་⛉ṑ⛉ᏛᏛ㝔 ་⒪ᨻ⟇ሗᏛศ㔝ᩍᤵ㸧 Speaker: Kiyohide Fushimi, Prof. of Health Policy and Informatics Section, Tokyo Medical and Dental University Graduate School
22 14:00ʛ14:55 Keynote Lectureʁվ㸦Japan ᪥ᮏ㸧 ʰOverview of the post-war Japanese medical care system and prospects of medical and long-term care policies in the advent of an ultra-aging societyʱ ʰᡓᚋ᪥ᮏࡢ་⒪ไᗘࡢᴫせ࠾ࡼࡧ㉸㧗㱋♫ࡀ฿᮶ࡍࡿ᪥ᮏ࠾ࡅࡿ་⒪࣭㛗ᮇㆤᨻ⟇ࡢᒎᮃʱ Chairman: Dr. Akira Yoshikawaʤ٤ઔ ໎ʥHonorary Director, Nagaoka Central General ݟਫ਼࿊ ௗԮԟබӅ໌༬Ӆௗʥ׃Hospital, Niigata, Japanʤ Speaker: Prof. Nanako Tamiya (Department of Health Services Research, Faculty of Medicine Research & Development Center for Health Services, University of Tsukuba)
15ʁ00ʛ15ʁ55 Keynote Lectureʁտ㸦India 䜲䞁䝗㸧 㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌 ʰGlobal challenges to Rural Health and Medicine, with special reference to the Elderly in Rural Areasʱ ʰᆅ᪉ࡢᗣ་⒪㛵ࡍࡿࢢ࣮ࣟࣂࣝㄢ㢟̿≉ᆅ᪉ࡢ㧗㱋⪅ࡘ࠸࡚ʱ Chairman: Dr. Yoshiaki SomekawaʤઝઔՆ໎ʥVice Director, JA Toride Medical Center, Ibaraki, JapanʤἜݟਫ਼࿊ JA ͳΕͲ૱ҫྏιϱνʖ෯Ӆௗʥ Speaker: Dr. Ashok Vikhe Patil (Executive Chairman, Pravara Rural Education Society, DIST-AHMEDNAGAR, Immediate Past President of International Association of Rural Health and Medicine (IARM))
16ʁ00ʛ17ʁ00 㛢ᘧࠊ⾲ᙲᘧࠊᮾிᐉゝ㸦ྜྠ㸧 Closing and Awards Ceremony (Joint) 2018 ᮾிᐉゝ䠄ྜྠᏛ㸸➨ 67 ᅇ᪥ᮏ㎰ᮧ་ᏛᏛ⾡⥲࣭➨ 20 ᅇᅜ㝿㎰ᮧ་ᏛᏛ⾡⥲䠅 2018 Tokyo Declaration: Joint Congress of 20th Congress of the International Association of Rural Health and Medicine (IARM) and 67th Annual Meeting of Japanese Association of Rural Health and Medicine (JARM)
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Program: Oral Session
Day 1: October 10㸦Wed.㸧Ꮫ 1 ᪥┠㸸10 ᭶ 10 ᪥㸦Ỉ㸧 Venue B㸦ሙ㸧TFT Hall 300
October 10, 10᭶10᪥, 10:00am - 10:32am Chairman : Atsushi Ueda㸦ୖ⏣ ཌ㸧ࠊDirector, East Asia Health Promotion Network Center 㸦ᮾࢪ࣊ࣝࢫࣉ࣮ࣟࣔࢩࣙࣥࢿࢵࢺ࣮࣡ࢡࢭࣥࢱ࣮ ࢭࣥࢱ࣮㛗㸧
O-1: Cost of inpatients with foot problems covered by health insurance in Japan andڦ measures against long hospital stay Jumpei Wato and Shinya Kashiwagi. Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine, Japan
O-2: Confronting the Crisis in Medical Education 㹼 ICARE: Five measures to supportڦ young physicians 㹼 SungHo(Narihiro) Chang(Chou), Aritaka Matsuyama, Chieko Benitani, Yuko Nakajima, Youichi Koizumi, Atsuhiro Matsuno, Jun Tsuyuzaki, Hideaki Sato, Kentaro Shimada, Takayuki Eizawa, Ryuichi Kai, Kenichi Ito, Kazuki Yochioka and Gotaro Kurasawa. Department of Internal medicine, Asama-Nanroku KOMORO Medical Center, Japan
O-3: A novel strategy for gastric cancer screening using a mobile van service equipped withڦ trans-nasal endoscopy Seiji Adachi, Eri Takada, Koki Obara, Yohei Horibe, Tomohiko Ohno, Midori Iwama, Osamu Yamauchi, Koshiro Saito, Shiki Yasue, Yuhei Kojima, Daisaku Hata, Satomi Nagaya, Yumiko Hara, Chizuru Hori, Nao Tsuji and Mayuko Kohno. Gihoku Kosei Hospital, Japan
O-4: Emergency medical service in Komono, Japanڦ Makoto Miki, Masuo Oohashi and Takafumi Kanazu. Komono kousei hospital, Japan
October 10, 10᭶10᪥, 10:35am - 11:15am Chairman: Kenji Kikuchi㸦⳥ᆅ㢧ḟ㸧ࠊHonorary Director, Yuri Kumiai General Hospital 㸦⏤⤌ྜ⥲ྜ㝔 ྡ㝔㛗㸧
:O-5: Elderly patients with proximal femoral fracture who return to living at homeڦ comparison of acute care and rehabilitation (kaifukuki) hospitals Koji Suzuki. JA Toride Medical Center, Japan
O-6: A new scoring model including bladder neck involvement for recurrence in patientsڦ with non-muscle-invasive bladder cancer Naoko Kawamura, Motohiro Fujiwara and Testuo Okuno. JA Toride Medical Center, Japan
O-7: AYURVED FOR CANCER IN RURAL AREAS: A HOLISTIC APPROACHڦ SUKUMAR SARDESHMUKH. BHARATIYA SANSKRITI DARSHAN TRUST's INTEGRATED CANCER TREATMENT AND RESEARCH CENTRE, WAGHOLI, PUNE, India
O-8㸸Empirical Study of homelessness and rapes in destitute mentally ill women found onڦ Indian roads and in rural area. Rajendra Dhamane, Sucheta Dhamane and Vasant Desale. NNG INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES, India
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O-9: Difference of health status and individual level social capital between participants andڦ non-participants to agricultural development project among rural older adults in Japan Yugo Shobugawa, Hiroshi Murayama, Takeo Fujiwara and Shigeru Inoue. Niigata University, Japan
October 10, 10᭶10᪥, 11:20am - 11:52am Chairman: Hiroshi Nagami㸦Ọ⨾ᚿ㸧ࠊDirector, Institute for Prevention of Pesticide Adverse Effect on Human㸦㎰⸆ேయᙳ㡪㜵Ṇ◊✲ᡤ ᡤ㛗㸧
O-10: Impact of public expense for the vaccine covered by rural governments on anڦ epidemic of rotavirus enteritis Yuko Sato, Yoshiaki Sasaki and Hiroki Kajino. Department of Microbiology, Fukushima Medical University School of Medicine, Japan
O-11: Our challenge to nurture community-oriented young doctors through overseasڦ primary health care training in collaboration with a medical school in Leyte Island, the Philippines Jumpei Hasumi, Masahiro Zakoji, Masahiko Sakamoto, Tetsuro Irohira, Akihiro Kitazawa and Kazuya Yui. Saku Central Hospital, Japan
O-12: HIGH RESOLUTION COMPUTERIZED TOMOGRAPHY (H.R.C.T.) FORڦ PULMONARY CHANGES IN SMOKE INHALATION IN A RURAL POPULATION DAYANAND SHETTY, SUNDEEP SALVI, BILL BRASHIER, SATISH PANDE, TEJASWI THAMATAM, SMITA KORI and SAJID TAMBE. K.E.M HOSPITAL, PUNE, India
O-13: Type of Rehabilitation Gardens in Sweden with Development of Nature Basedڦ Rehabilitation in Japan Mayuko Ishii, Chikako Haruki, Patrik Grahn, Shin-ichiro Sasahara and Yasuhito Hirai. Medical Corporation Shikoukai, Takase Clinic, Japan
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Program: Poster Session
Day 2: October 11㸦Thur.㸧Ꮫ 2 ᪥┠㸸10 ᭶ 11 ᪥㸦ᮌ㸧 㸦ሙ㸧TFT Hall 1000
Posters will be displayed between 9 am to 6 pm on Day 2, Oct.11, Thur. Tours for poster presentations are not provided in this IARM poster session. The presenters of the displayed posters will be available for questions and answers on Day 2, Oct.11, Thur. 4 pm-5pm.
P-1: Attitudes toward death and preparations for death among the community dwellingڦ elderly in Japan Michiko Sato-Komata, Akiko Hoshino, Mai Ogura, Nobuhito Ishikawa and Toshiki Katsura. Preventive Nursing, Department of Human Health Sciences, Graduate school of Medicine, Kyoto University, Japan
P-2: Risk Factors related to Low Physical and Mental QOL of Elderly Japanese resided in aڦ Rural Town, Ehime, Japan Mai Ogura, Michiko Komata-Sato, Nobuhito Ishikawa, Akiko Hoshino and Toshiki Katsura. Department of Human Health Sciences Graduate School of Medicine Kyoto University, Japan
,P-3: Risk Factors related to Social Isolation of Elderly Japanese resided in a Rural Townڦ Ehime, Japan Toshiki Katsura, Mai Ogura, Michiko Momata-Satoh, Nobuhito Ishikawa and Akiko Hoshino. Department of Human Health Sciences Graduate School ofMedicine Kyoto University, Japan
P-4: Nursing Practices for Fall Prevention in Hospitalized Elderly Patients with Dementiaڦ Miki Fukuma, Department of Nursing, Faculty of Medicine, Shimane University, Japan
P-5: Serial changes in Trail Making Test score in patients with mild ischemic strokeڦ Zen Kobayashi, Miho Yoshioka, Keisuke Inoue, Mayumi Watanabe, Kaori Kato, Kazunori Toyoda, Yoshiyuki Numasawa, Shoichiro Ishihara, Hiroyuki Tomimitsu and Shuzo Shintani. JA Toride Medical Center, Japan
P-6: A Study on Oral Health of Korean National Basic Livelihood Recipientsڦ Chang-Suk Kim, Department of dental hygiene, Ulsan College, Korea
P-7: Relationship between the patient's level of income and centralization of medicalڦ service utilization in cardio-cerebrovascular disease Min-Ah Nah, Kyeong-Soo Lee, Chang Suk Kim, Sang Won Kim, Tae-Yoon Hwang and Chang- Yoon Kim. Department of preventive medicine and public health, Yeungnam University, College of Medicine, Korea
P-8: Feasibility of endoscopic screening for upper gastrointestinal malignancies in aڦ complete medical checkup Sayaka Sato, Yohei Horikawa, Hiroya Mizutamari, Nobuya Mimori, Yuhei Kato, Masayuki Sawaguchi, Saki Fushimi and Syunji Okubo. Hiraka General Hospital, Japan
P-9: Significance of airborne pollen measurements as a tool to prevent Japanese pollinosisڦ at the community level in Japan Hidetoyo Teranishi, Toyama Kyoritsu Hospital, Toyama Health Cooperative, Japan
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P-10: Creation of Arena for Elderly Welfare in Japanese Agricultural Cooperativeڦ Yuko Kawakami, Kameda College of Health Sciences, Japan
P-11: A Study on the Expectation of Imlant in Koreansڦ Mi-Sook Cho, Choonhae College Dept. of Dental Hygiene, Korea
P-12: Health Awareness in Elderly Men Living alone: Aimed at four areas of depopulatedڦ and aged villages Kimie Fujikawa, Department of Nursing, Faculty of Health Sciences at Nihon Institute of Medical Science, Japan
P-13: Prevalence of diseases among agricultural workers in rural areas of Japan: Shimaneڦ CoHRE study. Masayuki Yamasaki, Shozo Yano, Miwako Takeda, Tsuyoshi Hamano, Kunie Kohno, Shimane CoHRE study members and Kuninori Shiwaku. Faculty of Human Sciences, Faculty of Medicine, the Center for Community-based Healthcare Research and Education (CoHRE), Shimane University, Japan
P-14: Barriers to health education service for the elderly patients with hypertension orڦ diabetes Yoon Kyung Kim, Tae-Yoon Hwang, Min-Ah Nah, Kyeong-Soo Lee and Chang-Yoon Kim. Center for hypertension and diabetes registry and education, Gyeongju-si, Korea
P-15: Common Upper Extremity Disorder, Function, and Upper Extremity-related Qualityڦ of Life: A Community-based Sample Residing in Rural Areas Mi-Ji Kim, Dong Kyu Moon and Ki Soo Park. Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University School of Medicine, Korea
P-16: WHO Disability Assessment Schedule 2.0 is related to Upper and Lower Extremityڦ disease Specific Quality of Life: A Community-based Sample Residing in Rural Areas Jun-Il Yoo, Ae-Rim Seo, Mi-Ji Kim, Bokyoung Kim and Ki Soo Park. Gyeongsang National University Hospital, Center for Farmer’s Safety and Health, Korea
P-17: Head, upper trunk, and lower trunk axial rotation angles in young baseball playersڦ with a history of throwing-related pain Masashi Kawabata, Toru Miyata, Hiroaki Tatsuki, Yohei Kusaba, Yuichi Kashiwazaki, Shigeru Ishii and Seigo Takano Rehabilitation Center, Sagamihara Kyodo Hospital, Japan
P-18: Relationships between limbs reach tests and range of motion in young baseballڦ players with a history of throwing-related pain Toru Miyata, Masashi Kawabata, Hiroaki Tatsuki, Yohei Kusaba, Yuichi Kashiwazaki, Shigeru Ishii and Seigo Takano. Rehabilitation Center, Sagamihara Kyodo Hospital, Japan
P-19: A single rural community hospital experience of simultaneous laparoscopicڦ cystectomy and laparoscopic nephroureterectomy with umbilical reduced port surgery outcome Takehiko Okamura, Ryosuke Chaya, Takashi Nagai, Yoshinobu Moritoki, Daichi Kobayashi and Hidetoshi Akita. Anjo Kosei Hospital, Japan
P-20: Statistical analysis of Ki-67 labeling index in breast cancer as prediction of prognosisڦ Maiko Kawai, Akio Kazama, Ichiro Maeda, Tomohiro Kimura, Daisuke Fujihira, Hisataka Onda, Shigeru Ishii and Seigo Takano. Clinical Laboratory, Japan
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P-21: The present conditions and the future prospects of the palliative radiotherapy in ourڦ hospital Shunji Okae, Anjo Kosei hospital, Japan
P-22: Spatial distribution and clusters of small area cancer incidence in Chungnamڦ province, South Korea Jee-Hyeon Choi and Hae-Sung Nam. Graduate School of Chungnam National University Department of Public Health, Korea
P-23: Active lifestyle related to well-being of elderly residents in a healthy city aiming atڦ successful aging Nobuhito Ishikawa, Akiko Hoshino, Miho Shizawa, Kanae Usui, Mai Ogura, Michiko Komata and Toshiki Katsura. Preventive Nursing, Department of Human Health Sciences, Graduate school of Medicine, Kyoto University, Japan
P-24: Social appearance (sekentei) and cognitive decline among community-dwelling olderڦ adults in rural Japan Hiroshi Murayama, Yugo Shobugawa, Takeo Fujiwara and Shigeru Inoue. Institute of Gerontology, The University of Tokyo, Japan
P-25: Relationship between Frailty and applied activities of daily in elderly people living inڦ low-rural rural areas 㹼Focusing on social behavior in indoor and outdoor㹼 Saki Ikedo, Yuka Matsumoto, Ryosuke Takagi and Wakaya Fujii. Department of Rehabilitation Tohno Kosei Hospital, Japan
P-26: Relationship between Frailty and physical and psychosocial factors in elderly peopleڦ living in lowlands rural areas -Examination of factors by discriminant analysis- Wakaya Fujii, Saki Ikedo, Yuka Matsumoto, Ryosuke Takagi and Hirofumi Hirowatari. Department of Rehabilitation, Major in Occupational Therapy, Gifu, Japan Junior college of Health Science
P-27: Association between mobile technology use and emotional/behavioral adjustment inڦ elementary school Rikuya Hosokawa and Toshiki Katsura. Nagoya City University, Japan
P-28: A case report of very late recurrence of epithelial ovarian cancer at an extremely rareڦ region: the Canal of Nuck after 26 years of disease free interval Ikuno Yamauchi, Tsuchiura Kyodo General Hospital, Japan
P-29: Difficulty of Response to Mental Patients Receiving Hemodialysis Therapy inڦ Dialysis- Health Care-Workers Ayako Fujita, Nihon Institute of Medical Science, Japan
P-30: The combination of Berg Balance Scale and Moss Attention Rating Scale forڦ assessment of walking independence in acute ischemic stroke Keisuke Inoue, Yoshiyuki Numasawa, Satoshi Sutou, Masaki Hakomori, Kazunori Toyoda and Hiroyuki Tomimitsu. JA Toride Medical Center, Japan
P-31: Examination of the effect of intervention of image training on patients with chronicڦ stroke Takahiro Takenaka and Yoshinori Kimigaki. Heisei College of Health Sciences, Japan
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President Lecture of JARM（Day 1）10 a.m.
Current State and Future Prospects of Clinical Application of Genome Medical Research Prof. Akira Hata Professor, Chiba University Graduate School of Medicine, Japan
Rapid progress in genome medical research has uncoverd the details of the hereditary factors of various disorders including lifestyle-related diseases such as diabetes. Namely, the involvement of specific genes (called susceptibility genes) in such disorders was revealed. For a long time, many medical experts and medical researchers have had the dream of preclinical risk assessment through the analysis of susceptibility genes in individuals to help prevent disease. Such an individualized medical approach has been called custom-made or tailored medicine and, more recently, personalized or precision medicine. “Genome” is a term created from “gene” and “ome (whole)” and refers to the complete human genome sequence of three billion base pairs. The Human Genome Project was launched in 1990 with the aim of sequencing all three billion base pairs of the human genome. A working draft of the genome was published in 2000 and a complete draft was published in 2003. Subsequently, the HapMap Project was started with the aim of mapping human genome polymorphisms called single nucleotide variants (SNVs) in more than 1,000 individuals from different ethnic groups. The achievements of this project were published five years later in 2008. Since then, genome analysis has progressed further. After companies in Europe and the U.S. developed and commercialized genome-wide association study (GWAS) kits for mapping SNVs of the entire genome simultaneously, the results of the GWAS confirmed the hypothesis that genes located near the SNVs showing differences between the patient population for a certain disease and the control population are responsible for that disease. Since then, genes responsible for multifactorial disorders such as diabetes, which used to be considered extremely difficult to identify, have been identified one after another. Genes affecting various genetic diseases, laboratory values, and multifactorial traits such as height have already been identified and made public. Also, as a result of the rapid progress in the next-generation sequencer (NGS) and the computer technology to process the obtained information, the analytical capacity has developed to the extent that it is possible to sequence the complete human genome of three billion base pairs several times a day. In addition, it was announced that the cost of sequencing the complete human genome of an individual had been reduced to about US$1,000 in 2014. On the basis of these advances, genes and mutations responsible for monogenic disorders and other diseases have been thoroughly analyzed, and major insights have been gained by exome sequencing, a technique for selectively decoding all base sequences of exons in the human genome. Genome medical research has become essential in the diagnosis of many monogenic disorders and has produced outstanding results in predicting the effectiveness and side effects of drugs and the selection of therapeutic agents on the basis of genome changes in cancer. On the other hand, the clinical application of genome medical research to multifactorial disorders, including lifestyle-related diseases, is far from sufficient at present.
Profile: 1972-1978 Kumamoto University School of Medicine, Kumamoto 1984-1988 Kumamoto University School of Medicine, Graduate School Ph.D. 1978-1980 Junior Resident, Division of Pediatrics, Okayama National Hospital 1980-1982 Senior Resident, Division of Medical Genetics, Kanagawa Children’s Medical Center 1982-1983 Senior Resident, Okayama National Hospital 1983-1984 Pediatrician, Nishibeppu Hospital 1988-1989 Pediatrician, Ashikita Gakuen Hospital 1989-1991 Research Associate, Howard Hughes Medical Institute University of Utah 1991-1992 Assistant Professor, Nagoya City University 1993-1998 Associate Professor, Hokkaido University School of Medicine 1998-2002 Professor, Asahikawa Medical College 2002-present Professor, Chiba University Graduate School of Medicine
30 日本農村医学会学術総会 会長講演（第 1 日目）10 a.m.
ゲノム医学研究の臨床応用の現状と今後の展望 羽田 明 千葉大学大学院医学研究院 環境健康科学講座公衆衛生学
ゲノム医学研究の急速な進展によって， 糖尿病などの生活習慣病を含む多くの疾患における遺伝要因の本態で ある具体的な遺伝子の関与（感受性遺伝子とよぶ）が明らかになってきた．個々人において関与する遺伝子を解 析する事によって，発症前リスクを評価することにより疾患予防に使う事ができるという考え方は，多くの医療 関係者や医学研究者が長い間，夢想していたことであった．この様な医療をオーダーメイド医療，テーラーメイ ド医療，最近では個別化医療（ personalized medicine），精密医療（ precision medicine）と呼ぶ．ゲノム （genome）という言葉は gene（遺伝子）と -ome（全体）を合体させた造語であり，ヒト塩基配列 30億塩基対全 体を意味する． この30億塩基対の暗号を全部，解読することをめざしたプロジェクトが， 1990年にはじまったヒトゲノム計 画である． 2000年には概要版， 2003年には完成版が公表された．引き続いて， 1000人以上の様々な人種のヒト ゲノムのSNVsと呼ばれる多型を解読しようというハップマッププロジェクトが始まり， 5年後の 2008年にその 成果が公表された．その後も解析が進み，欧米の会社によってゲノム全体を代表する SNVsを一気に解析する GWAS（genome-wide association study）キットが開発，販売される様になると，患者群と非患者群で違いが あるSNVsの近傍にある遺伝子がその疾患に関与する遺伝子であるとの仮説が正しいことがわかり，それまで極 めて難しいと思われていた，糖尿病などの多因子疾患に関与する遺伝子が続々と明らかになってきた．すでに多 くの遺伝性疾患や検査値， 身長などの形質 （多因子形質という） に関する遺伝子が明らかにされ， 公表されている． さらに次世代シーケンサー（ NGS）とその情報処理技術の急速な進歩により，解析能力としては 1日でヒトゲノ ムの30億塩基対を何度も読むことができるようになると共に， ヒト1人の全ゲノムを解読するコストも 2014年に は1,000ドル程度になったと発表されている．この進歩を利用して，ヒト遺伝子のエクソン部分のみの塩基配列 を全て解読してしまうエクソーム（ exome）解析により単一遺伝子病を中心に疾患の原因となる遺伝子とその変 異が徹底的に解析され，多くの知見が得られている． 多くの単一遺伝子病では診断に不可欠となり，薬の効果や副作用予測，がんにおけるゲノム変化に応じた治療 薬の選択などではめざましい成果を挙げている一方， 生活習慣病などの多因子疾患ではまだ十分に臨床応用がで きているとは言いがたいのが現状である．
略歴： 昭和53年 国立岡山病院小児科（研修医） 昭和55年 神奈川県立こども医療センター遺伝科（シニアレジデント） 昭和57年 国立岡山病院小児医療センター（チーフレジデント） 昭和58年 国立西別府病院小児科 昭和59年 熊本大学大学院医学研究科入学 平成1年 ハワードヒューズ医学研究所（ユタ大学）（Research Associate） 平成3年 名古屋市立大学医学部講師（生化学第二講座） 平成5年 北海道大学医学部助教授（公衆衛生学講座） 平成10年 旭川医科大学教授（公衆衛生学講座） 平成14年 千葉大学大学院医学研究院教授（環境健康科学講座公衆衛生学）
31 Special Lecture of JARM ①（Day 1）16 p.m.
Social Determinants of Health and Rural Medicine̶ Suggestions from Japan Gerontological Evaluation Study Prof. Katsunori Kondo Professor of social epidemiology and health policy at the Center for Preventive Medical Sciences and the Graduate School of Medicine at Chiba University
The origin of rural medicine dates back to when “farmer’s syndrome”, a common syndrome among farmers, became an epidemic in some rural villages. The symptoms commonly observed in rural areas differed from those in urban areas although people living in those areas were of the same species, Homo sapiens. Rural medicine aims to investigate the cause of such differences and measures that can be taken against them. The pioneers in the field of rural medicine went deep into rural villages, carried out epidemiological studies, found that farmer’s syndrome is attributable to the family, society, and environment surrounding farmers, and attempted to improve the environment as a part of their duties. Considering the above, rural medicine is thought to be one of the origins of social epidemiology, a growing field of epidemiology aimed at the clarification of social determinants of health. In this presentation, we discuss the impact of social determinants of health and the issues and potential of rural medicine on the basis of the epidemiological characteristics in rural areas observed from the data collected through a social epidemiological study project, the Japan Gerontological Evaluation Study (JAGES). A JAGES survey is conducted every three to four years. We received responses from 200,000 elderly people in 41 towns and cities across Japan in the survey conducted in 2016/2017. The analysis of the data revealed that, on the whole, the health conditions of elderly people in rural areas continued to be poorer than those in urban areas and that, for some health indicators, the number of elderly people with health risks in rural areas was three times greater than that in urban areas. For example, the number of people who had poor scores for indicators of depression, falling, dental health, dementia, and instrumental activity of daily living (IADL), which is the likelihood of requiring nursing care, was larger in rural areas than in urban areas. Some of the reasons for such results are found in society and the environment in rural areas. For example, people living in rural villages with little public transportation most often travel by car and spend little time walking on a daily basis. However, not all rural areas showed poor health indicators; there were rural areas where residents had good scores for health indicators. By investigating the characteristics of such areas, we found that there are not only factors that are difficult to achieve in the short term, such as economic wealth, but also factors that may be achieved through community intervention, such as a high participation rate in sporting activities. As a result of implementing community intervention aimed at creating places for social activities, the number of participants in such activities increased. Also, a follow-up study revealed that such community intervention led to a reduction in the incidence of certified need of care in the long- term care insurance system. There are some factors that cannot be observed unless an in-depth study is made of a rural village. On the other hand, we can easily see the characteristics of a rural area by comparing it with other urban or rural areas. Finding a healthy rural village, clarifying its characteristics, and knowing the activities being carried out there will provide clues to giving a practical and applicable prescription for the development of healthy rural villages. We hope that an increasing number of local governments as well as researchers and practitioners involved in rural medicine will join JAGES.
Profile: Dr. Kondo Katsunori is a Professor of social epidemiology and health policy at the Center for Preventive Medical Sciences and the Graduate School of Medicine at Chiba University. He is also Head of the Department of Gerontological Evaluation at the Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology. He is the author of bestselling books, “Health Gap Society - what undermining mental health and society? “, Igaku-Shoin, 2005, which is awarded in 2006 by The Society for the Study of Social Policy. He also wrote “Beyond 'healthcare crisis' - future of health and long term care in the UK and Japan”, Igaku-Shoin, 2012; “Prescriptions for Health Gap Society”, Igaku-Shoin, 2017; edited and wrote “Health Inequalities in Japan: An Empirical Study of the Older People”, Trans Pacific Press, Melbourne, 2010; ”Social Determinants of Health - reviews of 'health disparities' in Non Communicable Diseases”, Japan Public Health Association, 2013.
32 日本農村医学会学術総会 特別講演①（第 1 日目）16 p.m.
健康の社会的決定要因と農村医学ー JAGESからの示唆 近藤克則 千葉大学 予防医学センター 社会予防医学研究部門教授 国立長寿医療研究センター 老年学・社会科学研究センター老年学評価研究部長
農村医学の原点は，農夫に多く見られる症候群「農夫症」が多発していた農村にあった．同じ「ヒト」でも， 都市と農村とでは，多発する症状が異なる．その理由の探究と対策の研究，そして実践が，農村医学がめざすも のである．かつて農村医学の先達は，農村に分け入り，疫学調査を行い，農夫症が農夫を取り巻く家族―社会・ 環境に起因することを見出し，環境を改善することをも自らの仕事とした．こう考えてみると，健康の社会的決 定要因（social determinants of health）を解明する疫学の一分野として登場し広がりを見せる「社会疫学（social epidemiology」」の源流の1つを，農村医学に見出すことができる． 本講演では，社会疫学研究プロジェクトであるJAGES（Japan Gerontological Evaluation Study，日本老年 学的評価研究）データから見える農村的地域の疫学的特徴を元に，健康の社会的決定要因の影響の大きさと，農 村医学の課題と可能性について考えてみたい． JAGESでは，3-4年毎に一度の調査を繰り返しており，2016/17年には全国の41市町の高齢者20万人から回答 を得た．一連のデータを分析すると，現在でも農村的地域の高齢者の健康状態は，総じて都市部よりも悪く，一 部の指標ではリスクを持つ者が3倍も多いことがわかってきた．例えば，うつや転倒，歯科衛生，認知症や要介 護リスクであるIADL（手段的日常生活動作能力）低下者が多い．その理由の一部は，やはり社会・環境の中に 見出すことができた．農村的な地域ほど，公共交通機関が乏しいため車での移動が多く，1日の歩行時間は短い ことなどである． 一方で，すべての農村的地域で，健康指標が悪いわけではない．農村的な地域であっても，健康指標の良いと ころは実在する．そのような地域の特徴を探ってみると，経済的に豊かであるなど短期的には対策が難しい問題 ばかりでなく，スポーツの会への参加率が高いなど，地域介入の余地がある要因を見出すことができた．そこ で，通いの場を創出するような地域介入をしてみると，参加者は増加し，追跡すると要介護認定率を抑制しうる ことがわかってきた． 1つの農村に深く入り込まないと見えないことがある一方で，他地域（都市や農村）と比べることで，その地 域の特徴は見えやすくなる．健康な農村を見出し，その特性を解明し，そこでの取組みを知ることが，現実に適 用可能な「健康な農村づくり」の処方箋の手がかりを与えてくれる．より多くの市町村や農村医学研究・実践者 が，JAGESに参加して下さることを期待している．
略歴：1983年千葉大学医学部卒業．東京大学医学部付属病院リハビリテーション部医員，船橋二和（ふたわ）病院リハビリテーション 科科長などを経て，1997年日本福祉大学助教授．University of Kent at Canterbury（イギリス）客員研究員（2000-2001），日本福 祉大学教授を経て，2014年4月から現職 千葉大学予防医学センター 社会予防医学研究部門 教授．2016年4月から国立長寿医療研 究センター 老年学・社会科学研究センター 老年学評価研究部長を併任． 「健康格差社会－何が心と健康を蝕むのか」（医学書院，2005）で社会政策学会賞（奨励賞）受賞 近著 ｢健康格差社会への処方箋｣医学書院 2017
33 Educational Lecture of JARM（Day 3）13 p.m.
Utilization of healthcare big data to respond to a super aging society Kiyohide Fushimi, M.D., Ph.D. Professor and Section Chief, Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School
The population structure of our country is aging rapidly at an unprecedented speed in human history, securing a social security system that can respond to it is becoming an urgent policy issue of Japan. The government is promoting measures to improve regional medical care such as improving the efficiency of medical provision system by functional differentiation, and medical big data which has been improving in recent years is utilized there. The basic idea of function differentiation is to provide a delivery system according to necessary medical functions. Especially differentiation of acute care requiring many medical resources and convalescent / chronic medical care which maintain and restore the body function mainly for the elderly are major issues. Internationally from OECD statistics, this efficiency is an important issue, as the number of acute phase beds and the average number of hospital days per population in Japan are more than twice the average. Following the establishment of bills related to social security system reform in FY2004, review of the medical provision system based on analysis of medical big data is being promoted. Mainly used data include DPC data for analysis of acute care and community health care delivery system, the Medical Fee National Database (NDB) for medical fee analysis of all medical institutions, report on hospital function to visualize individual hospital ward functions, and government statistics such as patient survey. The government estimates medical demand by function by region by combining these big data and demographic estimation data. In addition, it urges prefectures to prepare a regional medical plan to respond to the future requirements of each medical function and to promote functional differentiation and cooperation and incorporate it into the medical plan. There is a criticism that estimating demand for each medical function uses medical fee points per day calculated from NDB and it is being simplified too much. However, rationality is recognized by understanding that it shows a reference value of functional differentiation by a standard method. Prefectures are to promote the development of a medical provision system capable of responding to medical functions by function estimated at the Regional Medical Care Conference, but various problems are becoming clear. Pain is associated with reduction of hospital beds in areas where medical demand contracts. Policy measures such as ensuring the effectiveness of conversion of hospital bed function and promotion of hospital bed improvement in areas where lack of bed is predicted are still being trial and error. Re-establishment of the medical provision system is a situation without waiting, it is desirable that fair and transparent discussion based on objective data be promoted.
Profile: Present: Professor and Section Chief, Department of Health Policy and Informatics Tokyo Medical and Dental University Graduate School. After graduating from the School of Medicine, Tokyo Medical and Dental University in 1985, he joined Tokyo Medical and Dental University Medical School Hospital, Health Department Medical Division Medical Guidance Auditing Office from 2010, and has been appointed Professor of Tokyo Medical and Dental University Medical Policy Informatics from 2010, comprehensive research of National Hospital Organization Headquarters. He is appointed general manager of center medical information analysis department. Health Science Labor Science Designated Research DPC Research Group Chief Researcher, Central Social Insurance Medical Association Medical Remuneration Survey Specialist Organization (DPC Evaluation Subcommittee), Cabinet Office Social Security System Reform Promotion Headquarters "Promotion of reform through the utilization of medical and nursing care information Professional Research Committee "Member.
34 日本農村医学会学術総会 教育講演（第 3 日目）13 p.m.
超高齢化社会に対応するための医療介護Big Dataの活用 伏見清秀 東京医科歯科大学大学院 医療政策情報学分野 教授 同医学部附属病院 クオリティマネジメント・センター長 国立病院機構本部総合研究センター 診療情報分析部長
わが国の人口構造は、人類史上前例のないスピードで急激に高齢化することが確実であり、それに対応できる 社会保障制度の確保が、我が国の喫緊の政策課題となっている。国は機能分化による医療提供体制の効率化など の地域医療整備の施策を推進しているが、そこには近年充実してきている医療ビッグデータが活用されている。 機能分化の基本的な考え方は、必要な医療機能に応じた提供体制の整備であり、特に多くの医療資源を要する急 性期医療と、主に高齢者のための身体機能を維持・回復させる回復期・慢性期医療の分化が大きな課題となって いる。OECD統計から国際的に見ると、わが国の人口あたり急性期病床数と平均入院日数は平均の2倍を超えて いることから、この効率化が重要な課題である。 平成26年度の社会保障制度改革関連諸法案の成立後、医療ビッグデータの解析に基づく医療提供体制の見直し が推進されている。主に用いられているデータは、急性期医療と地域医療提供体制の分析にDPCデータ、全医 療機関の診療報酬分析にレセプトナショナルデータベース（NDB）、個別の病院病棟機能を可視化する病床機能 報告、さらに患者調査等の官庁統計である。 政府は、これらのビッグデータと人口推計データを組み合わせて地域毎の機能別医療需要を推計した上で、都 道府県に対して、各医療機能の将来の必要量に対応するとともに機能分化と連携を推進するための地域医療構想 を策定して医療計画に盛り込むことを求めている。医療機能毎の需要推計にはNDBから計算される1日あたり診 療報酬点数が用いられていて、単純化されすぎているとの批判はあるが、標準的な手法で機能分化の参照値を示 すものと理解すれば合理性は認められる。都道府県は地域医療構想調整会議において推計される機能別医療需要 に対応できる医療提供体制の整備を進めることとなっているが、様々な課題が明らかとなってきている。医療需 要が縮小する地域における痛みを伴う病床の削減や機能転換の実効性の確保や、病床の不足が予測される地域に おける病床整備の推進などの政策手段はまだ試行錯誤が続けられている段階である。医療提供体制の再整備は 待ったなしの状況であり、客観的なデータに基づいた公平で透明な議論が進められることが望ましい。
略歴： 昭和60年 東京医科歯科大学医学部医学科卒業 平成07年 東京医科歯科大学医学部第二内科助手（腎臓内科） 平成09年 東京医科歯科大学医療情報部助手 平成10年 厚生省保険局医療課 医療指導監査室 特別医療指導監査官 平成12年 東京医科歯科大学大学院 医療情報システム学分野准教授 平成22年 東京医科歯科大学大学院 医療政策情報学分野教授 国立病院機構本部総合研究センター 診療情報分析部長（併任） 平成27年 東京医科歯科大学医学部附属病院 クオリティマネジメントセンター長（併任）
DPC関連研究班等 平成13年～平成21年 厚生労働科学研究DPC研究班コアメンバー 平成22年～ 厚生労働科学指定研究DPC研究班主任研究者 平成25年～ 中央社会保険医療協議会診療報酬調査専門組織（DPC評価分科会）委員 平成26年～ 内閣府社会保障制度改革推進本部「医療・介護情報の活用による改革の推進に関する専門調査会」構成員 平成27年～ 保健医療分野におけるICT活用推進懇談会委員 医療従事者の需給に関する検討会構成員
35 President Lecture of IARM（Day 1）11 a.m.
Home health care in patients with neurologic impairments in rural areas in Japan: (1) what is the long-term survival-determining factor? (2) Efficacy and ethics of artificial nutrition in the home health care Shuzo Shintani1,2, Zen Kobayashi1, Shouichirou Ishihara1, and Hisayuki Tomimitsu1 1Dept. of Neurology, JA Toride Medical Center, Ibaraki, Japan（日本） 2President, Japanese Association of Rural Medicine (JARM)
Key words: home health care, neurologic disease, dysphagia, efficacy and ethics, artificial nutrition supply, percutaneous endoscopic gastrostomy (PEG), home parenteral nutrition (HPN) Background: With Japanese becoming the longest-lived population in the world, the number of elderly persons requiring long-term care because of a bedridden state or dementia has been increasing remarkably. In 2025, the number of physically weak elderly who require medical, nursing, and social care support is expected to be 2.6 million, while the number of bedridden elderly with and without dementia will be 2.3 million (Fig.1). At home, difficulties of long-term care for bedridden elderly by family members have resulted in a “care-worn” state while undermining relationships between family members. In this condition, medical and nursing home care system has been increasingly important. A long-term care insurance system was established in Japan in 2000 because such care has become an increasingly serious issue.
Objective: In this study, we sought to identify factors that predict the long-term survival in Japanese patients receiving home health care for neurologic disorders. We also assessed the usefulness of artificial nutrition supply on the survival, such as home parenteral nutrition (HPN) or percutaneous endoscopic gastrostomy (PEG). The outcomes, in particular the survival, after receiving artificial nutrition remain unclear. Additionally, the efficacy of tube feeding for life prolongation in elderly patients remains controversial.
Patients and Methods: First, we retrospectively evaluated 180 patients with neurologic disease, who received home health care conducted by our hospital between 1992 and 2001(1). Our hospital is a 414-bed community teaching general hospital, and is located in Toride City, Ibaraki Prefecture, Japan (Fig.2). We divided the 180
Fig.1 Projected numbers of elderly people expected to be bedridden, demented, and physically weak in Japan
36 Toride City
࣭ ࣭ Tokyo
Ibaraki
Fig.2 Toride City, Ibaraki Prefecture, JapanToride patients with neurologic disease participating in our home health program into 5 subgroups; group 1, cerebrovascular disease group (n=103, 57.2%); group 2, Parkinsonism group (n=20, 11.1%); group 3, senile dementia of Alzheimer type (SDAT) group (n=18, 10.0%); group 4, motor neuron disease group (n=11, 6.1%); and group 5, other neurologic disease group (n=28, 15.6%) (Fig.3). Factors considered were age; gender; illnesses; prognosis; follow-up period; activities of daily living (ADL); behavioral, cognitive, and communicative functions; swallowing function; feeding method; serum nutritional values (total protein, albumin, and total cholesterol); hemoglobin concentration; and social care services provided at home. Next, we retrospectively evaluated 80 decreased patients with neurologic impairments who received home health care conducted by our hospital (2). They were divided into 3 groups according to the feeding method they had received: The oral-intake group (n=23); HPN group (n=21); and PEG group (n=36) (Table 1).
Results: After investigating the factors which determined the survival interval in 180 neurologic disease patients receiving home health care including 10 variables (age, gender, dysphagia level, ADL level, dementia level, and feeding method; serum concentrations of total protein, albumin, total cholesterol, and hemoglobin), age (P<0.0002) and dysphagia (P<0.04) were significant survival determinants by Cox’s proportional hazard test (Table 2). Kaplan-Meier curves indicated that survival was significantly shorter in the Parkinsonism group, and the mean level of dysphagia of this group was worst in the five subgroups (Fig.4). In the 3 groups according to the feeding method they had received, the PEG (736±765 days) and HPN (725±616 days) groups showed survival periods two-fold greater than that of the self-feeding oral-intake group (399±257 days) after receiving home health care, despite poorer conditions as indicated by the serum albumin concentration, swallowing function, ADL level, and cognitive function (Table 3).
Discussion: Cox’s proportional hazard test identified age and level of dysphagia as factors determining survival in patients with neurologic disease receiving home care. Despite the importance of eating and swallowing for bedridden patients, most patients in home health care have long-term problems with dysphagia. We have provided swallowing training for patients with dysphagia, indicating which foods in which form are most easily swallowed. Visiting nurses have educated family members, how to prepare food to make it more easily swallowed by patients with dysphagia. I think it is very important for bedridden patients to eat and swallow food by themselves, even if the amount is extremely small. Patients with oral intake with PEG or HPN fall in depressive state and loose human dignity after cessation of oral intake. In the elderly, dementia level is sometimes progressing after stopping oral intake. The meaning of oral intake by themselves is remarkable in home health care patients. When the amount of food by oral intake is not sufficient for their life support after swallowing training, additional feeding by PEG or HPN is necessary.
37 Fig.3 180 patients with neurologic impairments receiving home health care in Toride City, Japan between 1992 and 2001
Table 1 Neurologic impairments of 80 patients who received 3 methods of nutrition supply in home care before they died
Oral intake HPN PEG
(n=23) (n=21) (n=36)
Cerebral infarction/cerebral 17 10 23 hemorrhage/SAH Senile dementia of 24 3 Alzheimer type
Parkinson disease 13 7
ALS/SCD/NPH/HC 34 3
HPN, home parenteral nutrition; PEG, percutaneous endoscopic gastrostomy; SAH, subarachnoid hemorrhage; ALS, amyotrophic lateral sclerosis; SCD, spinocerebellar degeneration; NPH, normal pressure hydrocephalus; HC, Huntington chorea Cited by Reference 2
Table 2 Survival-determining factors in 180 patients with neurologic disease who received home health care in Toride City, Japan between 1992 and 2001
Age (P＜0.0002) and dysphagia (P＜0.04) are significant compared with other variables by Cox’s proportional hazard test.
Cited by Reference 1
38 100
90 ALS/SPMA/PBP (n=11) Senile dementia of Alzheimer type (n=18) S 80 u Parkison disease/ PSP/SND (n=20) r 70 v Cerebrovascular disease (n=103) i Others (n=28) v 60 a l 50
r 40 a t e 30
% 20
10
0 0 500 1000 1500 2000 2500 3000 3500 4000 4500 Survival days
Fig.4
Table 3 Characteristics of 80 patients with neurologic impairments who received 3 methods of nutrition supply in home care before they died
Oral intake HPN PEG (n=23) (n=21) (n=36)
Mean age when home health 76.9 ± 8.7 78.7 ± 7.7 77.3 ± 8.0 care started, years
Survival period after home 399 ± 257 ◎ 725 ± 616 736 ± 765 health care started, days
Mean level of dysphagia 1.9 ± 0.7‡ 3.7 ± 0.9 4.4 ± 0.8
Mean serum albumin 3.4 ± 0.5 3.4 ± 0.6 3.0 ± 0.5※ concentration (g/dl)
Mean level of activities of 3.3 ± 0.6‡ 4.4 ± 0.7 4.5 ± 0.8 daily living (ADL)
Mean level of dementia 2.4 ± 1.1※ 3.6 ± 1.1 3.9 ± 1.1
◎P＜0.05, ‡P＜0.001, ※ P＜0.01 by t-test compared with other groups. HPN, home parenteral nutrition; PEG, percutaneous endoscopic gastrostomy, Variables were scored 1 - 5 (1, normal or slightly involved; 2, mildly involved; 3, moderately involved; 4, severely involved; 5, extremely involved) as described in the text. Cited by Reference 2
The outcomes, particularly survival, after the start of HPN or PEG in home-care patients with severe neurologic impairments remain unclear. The efficacy of tube feeding for life prolongation in elderly patients with dementia remains controversial. However, this study demonstrated that the patients with PEG and HPN showed survival periods twice that of the self-feeding oral-intake patients after receiving home care despite lower serum albumin concentration (for PEG patients), reduced swallowing function and cognitive function, and poorer levels of ADL. Almost all of the patients were not capable of deciding whether they should receive artificial nutrition or not owing to dementia or poor cognizance (Table 4). Finally, the attitudes towards life-prolonging measures are known to vary greatly between countries. In Japan, it has been usually decided by family members, especially by a key person. Physicians should provide clinical evidence to the families before performing PEG or HPN and support their decisions to maintain the dignity of the patients.
39 Table 4 Almost all of the patients were not capable of deciding whether they should receive artificial nutrition (PEG or HPN) or not owing to dementia or poor cognizance.
Natural survival period Receiving informed Time of starting PEG or Neurologic disease after developing the consent from the HPN illness (years) patient
Stroke (extremely involved) mRS:5 2 to 3 years At the initial hospitalization impossible
Stroke (severely involved) mRS:4 5 to 10 years At the initial hospitalization almost impossible
Stroke (moderately involved) mRS:3 10 to 20 years PEG or HPN is rare sometimes possible
Wallenberg syndrome 20 years At the initial hospitalization possible
At the end stage of the Dementia of Alzheimer type (AD) 20 years impossible illness At the end stage of the Diffuse Lewy body disease (DLBD) 10 years impossible illness At the end stage of the Parkinson disease (PD) 15 years almost impossible illness At the end stage of the Multiple system atrophy (MSA) 8 years possible illness At the end stage of the Amyotrophic lateral sclerosis (ALS) 3 to 5 years possible illness The survival period is estimated up to the time when the patient can no longer receive mechanical ventilation. mRS, modified Rankin Scale; HPN, home parenteral nutrition; PEG, percutaneous endoscopic gastrostomy Cited by Reference 2
■ References (1) Shuzo Shintani, Tatsuo Shiigai. Survival-determining factors in patients with neurologic impairments who received home health care in Japan. J Neurol Sci 225:117-123, 2004 (2) Shuzo Shintani. Efficacy and ethics of artificial nutrition in patients with neurologic impairments in home care. Journal of Clinical Neuroscience 20: 220-223, 2013
Profile: Present position: Director, JA Toride Medical Center, Ibaraki, Japan President, Japanese Association of Rural Medicine (JARM) Secretary General, International Association of Rural Health and Medicine (IARM) Dr. Shintani had graduated from Tokyo Medical and Dental University (TMDU), Tokyo, Japan in 1979. After completing his residency programs at TMDU, he has been a member of the Department of Neurology of TMDU since 1986, and a clinical professor of TMDU since 2004. The Japanese Neurological Society certificated him in 1984. He has been a member of JARM since 1990 and been currently the Editor-in-Chief of Journal of Rural Medicine (JRM), an official journal of two associations, IARM and JARM. His expert theme are Neurology and Psychiatry, Rehabilitation Medicine, and Home Health Care.
40 41 IARM 会長講演（第 1 日目）11 a.m.
日本の地域における神経疾患患者の在宅医療： （1）長期生存期間の決定因子 （2）在宅医療における人工的栄養管理の有用性と倫理性 Shuzo Shintani1,2, Zen Kobayashi1, Shouichirou Ishihara1, and Hisayuki Tomimitsu1 1Dept. of Neurology, JA Toride Medical Center, Ibaraki, Japan 2President, Japanese Association of Rural Medicine (JARM)
Key words: home health care, neurologic disease, dysphagia, efficacy and ethics, artificial nutrition supply, percutaneous endoscopic gastrostomy (PEG), home parenteral nutrition (HPN) 背景： 世界最長寿国となった日本では、寝たきりや認知症のために長期介護を必要とする高齢者が著増している。 2025年には、身体的な衰えのために医療、看護、社会的支援を必要とする高齢者が260万人に達し、認知症およ び非認知症を含めた寝たきりの高齢者は230万人に達すると予想されている（図1）。寝たきりの高齢者を家族が 在宅で介護する場合、長期介護に伴う問題が「介護疲れ “care-worn” state」の状態を生じさせ、同時に家族間 の関係をむしばんでもいる。このような状況において、在宅医療看護システムの重要性はますます高まってい る。長期介護問題の深刻さが増すのを受けて、日本では2000年に長期介護保険制度（long-term care insurance system）が創設された。
目的： 本研究では、神経疾患のために在宅介護を受けている日本人患者の長期生存期間を予測する因子を検討した。 また、在宅静脈栄養法（HPN）や経皮内視鏡的胃瘻造設術（PEG）などの人工的栄養補給が生存期間に与える 影響も評価した。これまで、治療成果、特に人工的栄養補給開始後の生存期間について明確な検討はされておら ず、また、高齢患者の延命を目的とした経管栄養法の有効性も議論の的となっている。
対象と方法： まず、1992年から2001年の間に当病院の在宅医療（訪問看護）を受けた神経疾患患者180人をレトロスペク ティブに検討した（文献1）。当病院はベッド数414の地域教育型総合病院（414-bed community teaching general hospital）で、日本の茨城県取手市にある（図2）。当病院の在宅医療プログラムに参加した180人の神経疾患患 者を5つのサブグループに分けた。グループ1、脳血管疾患グループ（n = 103、57.2%）；グループ2、パーキン ソン病グループ（n = 20、11.1%）；グループ3、アルツハイマー型老年認知症（SDAT）グループ（n = 18、 10.0%）；グループ4、運動神経疾患グループ（n = 11、6.1%）；グループ5、その他の神経疾患グループ（n = 28、 15.6%）（図3）。検討した因子は、年齢、性別、疾患、予後、フォローアップ期間、日常生活動作（ADL）、行動
図1 Projected numbers of elderly people expected to be bedridden, demented, and physically weak in Japan
42 取手市
࣭ ࣭ 東京
茨城県
図2 取手市, 茨城県, 日本
図3 180 patients with neurologic impairments receiving home health care in Toride City, Japan between 1992 and 2001
/認知/意志伝達機能、嚥下機能、栄養補給法、血中栄養成分値（総タンパク量、アルブミン、総コレステロール）、 ヘモグロビン濃度、在宅で受けている社会的ケアサービスである。 次に、当院の在宅訪問看護を受けた後、死亡した神経疾患患者80人をレトロスペクティブに評価した（文献 2）。患者は、栄養補給方法にしたがって3グループ、すなわち、経口摂取グループoral-intake group（n = 23）、 HPNグループ（n = 21）、PEGグループ（n = 36）に分けた（表1）。
結果： 在宅訪問看護を受けた神経疾患患者180人について、生存期間を決定する因子（10変数、すなわち、年齢、性 別、嚥下障害レベル、ADLレベル、認知症レベル、栄養補給法、および総タンパク量、アルブミン、総コレス テロール、ヘモグロビン濃度）を調査した。Cox比例ハザードテストによる検討では、年齢（P＜0.0002）およ び嚥下障害（P＜0.04）が、生存期間の有意な決定因子であった（表2）。カプラン・マイヤー曲線、パーキンソ ン病グループで生存期間が有意に短く、同グループの嚥下障害の平均レベルは5つのサブグループ中最も高いこ とが示された（図4）。 栄養補給方法によって分けた3グループでは、PEG（736 ± 765日）およびHPN（725 ± 616日）グループに おける在宅介護開始後の生存期間は、自己経口摂取グループ（399 ± 257日）の生存期間と比較して2倍（two- fold greater）であった。PEGおよびHPNグループの血中アルブミン濃度、嚥下機能、ADLレベル、認知機能 は、自己経口摂取グループより低いにもかかわらず、このような結果が得られた（表3）。
43 表1 80名の神経疾患患者が、死亡する前に在宅ケアで受けていた3通りの栄養補給方法
Oral intake HPN PEG
(n=23) (n=21) (n=36)
Cerebral infarction/cerebral 17 10 23 hemorrhage/SAH Senile dementia of 24 3 Alzheimer type
Parkinson disease 13 7
ALS/SCD/NPH/HC 34 3
HPN, home parenteral nutrition; PEG, percutaneous endoscopic gastrostomy; SAH, subarachnoid hemorrhage; ALS, amyotrophic lateral sclerosis; SCD, spinocerebellar degeneration; NPH, normal pressure hydrocephalus; HC, Huntington chorea 文献2から引用
表2 Survival-determining factors in 180 patients with neurologic disease who received home health care in Toride City, Japan between 1992 and 2001
Age (P＜0.0002) and dysphagia (P＜0.04) are significant compared with other variables by Cox’s proportional hazard test.
文献１から引用
100
90 ALS/SPMA/PBP (n=11) Senile dementia of Alzheimer type (n=18) S 80 u Parkison disease/ PSP/SND (n=20) r 70 v Cerebrovascular disease (n=103) i Others (n=28) v 60 a l 50
r 40 a t e 30
% 20
10
0 0 500 1000 1500 2000 2500 3000 3500 4000 4500 Survival days
図4
44 表3 死亡する前に在宅ケアで受けていた3通りの栄養補給方法で分類した80名の神経疾患患者の特徴 Oral intake HPN PEG (n=23) (n=21) (n=36)
Mean age when home health 76.9 ± 8.7 78.7 ± 7.7 77.3 ± 8.0 care started, years
Survival period after home 399 ± 257 ◎ 725 ± 616 736 ± 765 health care started, days
Mean level of dysphagia 1.9 ± 0.7‡ 3.7 ± 0.9 4.4 ± 0.8
Mean serum albumin 3.4 ± 0.5 3.4 ± 0.6 3.0 ± 0.5※ concentration (g/dl)
Mean level of activities of 3.3 ± 0.6‡ 4.4 ± 0.7 4.5 ± 0.8 daily living (ADL)
Mean level of dementia 2.4 ± 1.1※ 3.6 ± 1.1 3.9 ± 1.1
◎P＜0.05, ‡P＜0.001, ※ P＜0.01 by t-test compared with other groups. HPN, home parenteral nutrition; PEG, percutaneous endoscopic gastrostomy, Variables were scored 1 - 5 (1, normal or slightly involved; 2, mildly involved; 3, moderately involved; 4, severely involved; 5, extremely involved) as described in the text. 文献2から引用
表4 ほとんどの患者さんは、その時に、人工的栄養補給（PEG or HPN）を受けるべきか否か、 認知障害や認識力低下のため、自分自身では判断できない。
Natural survival period Receiving informed Time of starting PEG or Neurologic disease after developing the consent from the HPN illness (years) patient
Stroke (extremely involved) mRS:5 2 to 3 years At the initial hospitalization impossible
Stroke (severely involved) mRS:4 5 to 10 years At the initial hospitalization almost impossible
Stroke (moderately involved) mRS:3 10 to 20 years PEG or HPN is rare sometimes possible
Wallenberg syndrome 20 years At the initial hospitalization possible
At the end stage of the Dementia of Alzheimer type (AD) 20 years impossible illness At the end stage of the Diffuse Lewy body disease (DLBD) 10 years impossible illness At the end stage of the Parkinson disease (PD) 15 years almost impossible illness At the end stage of the Multiple system atrophy (MSA) 8 years possible illness At the end stage of the Amyotrophic lateral sclerosis (ALS) 3 to 5 years possible illness The survival period is estimated up to the time when the patient can no longer receive mechanical ventilation. mRS, modified Rankin Scale; HPN, home parenteral nutrition; PEG, percutaneous endoscopic gastrostomy 文献2から引用
検討： Cox比例ハザードテストによると、在宅訪問看護を受けた神経疾患患者において、年齢および嚥下障害レベル が生存期間を決定する因子として特定された。寝たきり患者にとって食事や嚥下は重要だが、その患者の多くが 嚥下障害という長期的問題を抱えている。当病院では、嚥下障害のある患者に嚥下訓練（swallowing training） を行い、どのような種類また形状の食物が最も飲み込みやすいかを伝えている。訪問看護師は家族に対して、嚥 下障害のある患者がより簡単に飲み込める食事・食物について指導している。 寝たきり患者にとって、たとえごく少量であっても、自分自身で食物を食べ飲み込むことは非常に重要であ る。経口摂取と併用してPEGまたはHPNを受けていた患者が、経口摂取を中止すると抑うつ状態になり人間と しての尊厳を失っていく、また、高齢者で経口摂取の中止後に認知症レベルが進行する場合もある。在宅訪問看 護を受ける患者にとって、自分自身で経口摂取することの意義は大きい。嚥下訓練（swallowing training）を しても、経口摂取できる食物量が生命を維持するには足りない場合、PEGまたはHPNによる人工的な栄養補給 を検討することになる。
45 これまで、特に、重症神経疾患で在宅訪問看護を受けている患者のHPNまたはPEG開始後の生存期間につい て明らかにされて来なかった。さらに、認知症の高齢患者に対して延命目的で行う経管栄養法の有効性も議論の 的となっている。しかし、本研究では、PEGおよびHPNを受けた患者の在宅介護開始後の生存期間が、血中ア ルブミン濃度（PEG患者の場合）、嚥下および認知機能、ADLレベルが低いにもかかわらず、自己経口摂取患者 （self-feeding oral-intake patients）の生存期間と比較して2倍であることが明らかになった。しかし、ほとんど の患者は、認知症または認知力の低下により、その開始時に、人工的栄養補給を受けるべきか否かを自分で決定 することができない（表4）。また、人工的延命医療処置に対する考え方は、国によって大きく異なることが知ら れている。日本では、通常は家族、とりわけ家族内の主要人物（key person）によって決定されることが多い。 主治医は、PEGまたはHPNなどの選択をするにあたり、家族に対して臨床像を説明し、その患者の尊厳を保つ 決定ができるようにサポートすることが必要である。
■ 文献 (1) Shuzo Shintani, Tatsuo Shiigai. Survival-determining factors in patients with neurologic impairments who received home health care in Japan. J Neurol Sci 225:117-123, 2004 (2) Shuzo Shintani. Efficacy and ethics of artificial nutrition in patients with neurologic impairments in home care. Journal of Clinical Neuroscience 20: 220-223, 2013
略歴：現在、JAとりで総合医療センター院長、日本農村医学会（JARM）理事長、国際農村医学会（IARM）事務総長。1979年、東京 医科歯科大学・医学部を卒業、residency programを終了後、1986年、同大学脳神経内科に入局、2004年に臨床教授。1984年に日 本神経学会専門医、1990年から日本農村医学会（JARM）に入会、現在、JARM とIARM の共通機関誌のJournal of Rural Medicine （JRM）の編集長。専門は、神経学、精神医学、リハビリテーション医学、在宅ヘルスケア。
46 47 IARM Keynote Lecture ①（Day 1）14 p.m.
Healthy and sustainable workplaces for older workers in agriculture - A Swedish perspective Prof. Peter Lundqvist2, Dr. Kerstin Nilsson1,2 （スウェーデン） 1Lund University, Division of Occupational and Environmental Medicine, Lund, Sweden 2Swedish University of Agricultural Sciences, Department of Work Science, Business Economic & Environmental Psychology, Alnarp, Sweden Introduction: The number of older workers is increasing due to the demographic change with more elderly people [1- 4]. Sweden has, as the other Nordic country, one of Europe’s highest labour force participation rates among older workers. The demographic change with increased amount of older workers is one of the Swedish labour markets greatest challenges. Agricultural workers in Sweden as in other countries are already over-represented in the old age workforce and work more often than those in other occupations until older age [5-8]. However, there is a high incidence of work-related accidents and demands in agriculture and a number of studies highlight the importance of preventing injuries and promoting the health of older agricultural workers [9-16]. Elderly workers seem to suffer a higher risk of injuries [7-22]. Approximately 38 per cent of those who die from work-related injuries in Sweden are 55 years or older [21-22], but roughly 60 per cent of those who die from work-related injuries in agriculture are 55 years or older. The ability to work to a higher age is a complex and multidimensional issue that includes many factors [4,6-8; 23-26]. Today societies focus mostly on chronological ageing and are looking to increase the retirement age with regard to statutory pension systems, e.g. beyond 65 years of age to 69 years. When aiming to provide a sustainable working life for the increasing numbers of older workers in modern society the interactions between chronological, mental, biological and social ageing need to be considered in relation to working life factors and measures. The swAge-model is developed by grounded theory and out from literature reviews as well as qualitative, quantitative and interventions projects in the research group [4,6-8; 23-26]. The swAge model include the complex picture of factors and areas of importance to work life participation. In the model, different ageing concepts is related to the nine areas of importance for individuals perspective of work life participation and the four consideration areas to if individuals can and want to participate in an extended working life or not. The model also relate individual level to four activity areas including proposed measures at the organisation/enterprise level and at the society level. The model intend to increase the understanding and to be a tool in the work to create a more sustainable working life not only for older workers but for all ages. Because also the younger workers will hopefully be an older worker one day.
■ Reference [1] ILO. Good Practices in Labour Inspection. The Rural Sector with Special Attention to Agriculture. Geneva: International Labour Offices; 2011. [2] OECD. Population Pyramids in 2000 and 2050. OECD Statistics Portal: Demography and Population; 2007. [3] Head L. Baker PM.A. Bagwell B. Moon NW. Barriers to evidence based practice in accommodations for an aging workforce. Work, 2006;27:391–396. [4] Nilsson K. To work or not to work in an extended working life? Factors in working and retirement decisions. Acta Universitatis Agriculturae Sueciae; 2013. [5] Statistic Sweden. Jordbruksföretag och företagare 2016. [Agricultural holdings and holders in 2016] Rapport JO 34 SM 1701; 2017 http://www2.jordbruksverket.se/download/18.46c0f1c15bdc52ff7cd555c/ 1494318842971/JO34SM1701.pdf (in Swedish) [6] Nilsson K. Conceptualization of ageing in relation to factors of importance for extending working life – a review. Scandinavian Journal of Public Health 2016; 44: 490–505. http://journals.sagepub.com/doi/pdf/ 10.1177/1403494816636265
48 [7] Nilsson K. Interventions to reduce injuries among older workers in agriculture: A Review of evaluated intervention projects. Work: A Journal of Prevention, Assessment & Rehabilitation. 2016;55(2):471-480. DOI: 10.3233/WOR-162407 [8] Pinzke S. Nilsson K. Lundqvist P. Farm tractors on Swedish public roads--age-related perspectives on police reported incidents and injuries. Work 2014;49(1):39-49 [9] Hernandez-Peck M.C. Older Farmers: Factors Affecting Their Health and Safety. Centre for Studies in Aging School of Social Work and Human Services, Eastern Washington University; 2008. [10] Villosio C. et al Working Conditions of an Ageing Workforce. European Foundation for the Improvement of Living and Working Condition; 2008. [11] Thelin A. Holmberg S. Farmers and retirement: a longitudinal cohort study. Journal of Agromedicine, 2010;15(1):38-46. [12] Mitchell L. Hawranik P. Strain L. Age-related Physiological Changes: Considerations for Older Farmers’ Performance of Agricultural Tasks. Winnipeg, Centre of Aging, University of Manitoba, Canada; 2002. [13] Mayers JR Layne LA. Marsh SM. Injuries and fatalities to U.S. farmers and farm workers 55 years and older. American Journal of Industrial Medicine, 2009;52:185-194 [14] Lilley R. Day L. Koehncke N. Dosman J. Hagel L. William P. The relationship between fatigue-related factors and work-related injuries in the Saskatchewan farm injury cohort study. American Journal of Industrial Medicine, 2012;55:367-375. [15] Walters JK. Olson R. Karr J. Zoller E. Cain D. Douglas JP. Elevated occupational transport fatalities among older workers in Oregon: An empirical investigation. Accident Analysis and Prevention, 2013;53:28-38. [16] Caffaro F. Lundqvist P. Micheletti Cremasco M. Nilsson K. Pinzke S. Cavallo E. Being a farmer at old age: an ergonomic analysis of work-related risks in a group of Swedish farmers aged 65 and over. Journal of Agromedicine (accepted for publication 20170509) [17] Lundqvist P. Ökad säkerhet inom jordbruket – interventioner och andra strategier. [Increased Safety in Agriculture - Interventions and Other Strategies] Rapport 2012:15. Swedish Work Environment Authority; 2012. (in Swedish) [18] Rautiainen R, Lehtola MM, Day LM, Schonstein E, Suutarinen J, Salminen S, Verbeek JH. Interventions for Preventing Injuries in the Agricultural Industry (Review). The Cochrane Library, 2009, Issue 3. [20]Collin McLaughlin A. Sprufera JF. Aging farmers are at risk for injuries and fatalities: how human-factors research and application can help. North Carolina Medical Journal, 2011;72(6): 481-483. [21] Swedish Work Environment Authority. Korta arbetsskadefakta, Jordbruk [Brief Statistics on Work-related Injuries in Agriculture]. Nr 2/2009. (in Swedish). [22] Swedish Work Environment Authority. Arbetsskador 2013 [Occupational Accidents and Work-related Diseases] Arbetsmiljöstatistik Rapport 2014:1. Stockholm: Swedish Work Environment Authority; 2014. (in Swedish). [23] Nilsson K. Why work beyond 65? Discourse on the decision to continue working or retire early. Nordic Journal of Working Life Studies 2012; 2(3):7-28 [24] Nilsson K. Rignell-Hydbom A. Rylander L. Factors influencing the decision to extend working life or to retire. Scand Journal of Work Environment & Health. 2011; 37(6):473-480. [25] Nilsson K. The Influence of Work Environmental and Motivation Factors on Seniors’ Attitudes to an Extended Working Life or to Retire. A Cross Sectional Study with Employees 55 - 74 Years of Age. Open Journal of Social Sciences, 2017;5:30-41 [26] Nilsson K. Pinzke S. Lundqvist P. Occupational Injuries to Senior Farmers in Sweden: Journal of Agricultural Safety & Health. 2010; 16(1):19-29.
Profile: Kerstin Nilsson is Docent (Reader/Associate professor) in Public Health direction of Epidemiology; Dr.Med.Sc. Public Health in direction of Epidemiology; PhD Work Science. She works as a researcher and university lecturer at the Division of Occupational and Environmental Health, Faculty of Medicine, Lund University Sweden & Swedish University of Agricultural Sciences, Department of Work Science, Economic & Environmental Psychology, Alnarp, Sweden. Kerstin main research area since 2003 is older worker and she has developed the theoretical model of a sustainable working life for all ages – swAge-model (http://www.swage.org/) and written ca 70 publications
49 IARM 基調講演 ①（第 1 日目）14 p.m.
農業に従事する高齢労働者の健康的かつ持続 可能な労働環境：スウェーデンにおける考察 Prof. Peter Lundqvist2, Dr. Kerstin Nilsson1,2 （スウェーデン） 1Lund University, Division of Occupational and Environmental Medicine, Lund, Sweden 2Swedish University of Agricultural Sciences, Department of Work Science, Business Economic & Environmental Psychology, Alnarp, Sweden
人口構造が変化し、高齢者が増加したことに伴い、高齢労働者の数も増加している[1-4]。他の北欧諸国と同 様、スウェーデンもヨーロッパで最も高齢者の就労率が高い国の一つである。人口構造の変化で高齢労働者の数 が増えたことは、スウェーデンの労働市場にとって最大の課題（the Swedish labour markets greatest challenges）となっている。 他の国々と同様、スウェーデンでも農業労働者は高齢労働人口の中で既に高い比率を占めており、他の職業の 労働者よりも高齢になるまで（until older age）働く場合が多い [ 5-8 ]。しかし、農業においては業務上の事故 （work-related accidents）や緊急事態の発生率が高いため、怪我を防止し、高齢農業労働者の健康を維持する ことの重要性が多くの研究によって指摘されている [ 9-16 ]。高齢労働者は、怪我のリスクが高い [ 7-22 ]。ス ウェーデンにおいて業務上の怪我で亡くなった人の約38%は55歳以上であるが [ 21-22 ]、農業従事者の業務上 の怪我（work-related injuries in agriculture）で亡くなった人は、約60%が55歳以上である。 高齢まで働く能力というのは、多くの要素を含む複雑かつ多面的な問題（complex and multidimensional issue）である [ 4, 6-8, 23-26 ]。現在、スウェーデンは主に実年齢の高齢化（chronological ageing）に目を向 け、法定年金制度（statutory pension systems）との関連で退職年齢の引き上げ（たとえば65歳以上から69歳 への引き上げ）を目指している。現代社会で増加する高齢労働者に対し、持続可能な労働環境を提供することを 目指すのであれば、実年齢上、精神的（mental）、生物学的（biological）、社会的高齢化（social ageing）の相 互作用を労働環境上の要素や対策と関連付けて検討する必要がある。 swAgeモデルは、グラウンデッド・セオリー（grounded theory）に基づき、当研究グループの文献レビュー や、質的（qualitative）かつ量的（quantitative）プロジェクト、さらに、介入（interventions）プロジェク トから生み出されたモデルであり [ 4, 6-8, 23-26 ]、労働参加に関わる要素や重要分野の複雑な全体像を描いて いる。このモデルでは、高齢化のさまざまな概念（different ageing concepts）を、労働参加を個人の視点で捉 えた9つの重要分野と関連付けし、さらに、個人が労働参加を継続できるか否か、また、継続したいか否かを考 慮する場合の4つの検討分野とも関連付けている。加えて、これら個人レベルの分野が、組織・企業レベル （organisation/enterprise level）、社会レベル（society level）での対策案を含む4つの活動分野と関連付けてい る。このモデルは、理解を深めるとともに、仕事場において、高齢労働者だけでなくすべての年齢層の労働者に とって持続可能な労働環境（sustainable working life）を構築するためのツールとなるべく作成されている。な ぜなら、若い労働者もやがて高齢労働者になるからである。
■ References [1] ILO. Good Practices in Labour Inspection. The Rural Sector with Special Attention to Agriculture. Geneva: International Labour Offices; 2011. [2] OECD. Population Pyramids in 2000 and 2050. OECD Statistics Portal: Demography and Population; 2007. [3] Head L. Baker PM.A. Bagwell B. Moon NW. Barriers to evidence based practice in accommodations for an aging workforce. Work, 2006;27:391–396. [4] Nilsson K. To work or not to work in an extended working life? Factors in working and retirement decisions. Acta Universitatis Agriculturae Sueciae; 2013. [5]Statistic Sweden. Jordbruksföretag och företagare 2016. [Agricultural holdings and holders in 2016] Rapport JO 34 SM 1701; 2017 http://www2.jordbruksverket.se/download/18.46c0f1c15bdc52ff7cd555c/ 1494318842971/JO34SM1701.pdf (in Swedish) [6] Nilsson K. Conceptualization of ageing in relation to factors of importance for extending working life – a review. Scandinavian Journal of Public Health 2016; 44: 490–505. http://journals.sagepub.com/doi/pdf/ 10.1177/1403494816636265
50 [7] Nilsson K. Interventions to reduce injuries among older workers in agriculture: A Review of evaluated intervention projects. Work: A Journal of Prevention, Assessment & Rehabilitation. 2016;55(2):471-480. DOI: 10.3233/WOR-162407 [8] Pinzke S. Nilsson K. Lundqvist P. Farm tractors on Swedish public roads--age-related perspectives on police reported incidents and injuries. Work 2014;49(1):39-49 [9] Hernandez-Peck M.C. Older Farmers: Factors Affecting Their Health and Safety. Centre for Studies in Aging School of Social Work and Human Services, Eastern Washington University; 2008. [10] Villosio C. et al Working Conditions of an Ageing Workforce. European Foundation for the Improvement of Living and Working Condition; 2008. [11] Thelin A. Holmberg S. Farmers and retirement: a longitudinal cohort study. Journal of Agromedicine, 2010;15(1):38-46. [12] Mitchell L. Hawranik P. Strain L. Age-related Physiological Changes: Considerations for Older Farmers’ Performance of Agricultural Tasks. Winnipeg, Centre of Aging, University of Manitoba, Canada; 2002. [13] Mayers JR Layne LA. Marsh SM. Injuries and fatalities to U.S. farmers and farm workers 55 years and older. American Journal of Industrial Medicine, 2009;52:185-194 [14] Lilley R. Day L. Koehncke N. Dosman J. Hagel L. William P. The relationship between fatigue-related factors and work-related injuries in the Saskatchewan farm injury cohort study. American Journal of Industrial Medicine, 2012;55:367-375. [15] Walters JK. Olson R. Karr J. Zoller E. Cain D. Douglas JP. Elevated occupational transport fatalities among older workers in Oregon: An empirical investigation. Accident Analysis and Prevention, 2013;53:28-38. [16] Caffaro F. Lundqvist P. Micheletti Cremasco M. Nilsson K. Pinzke S. Cavallo E. Being a farmer at old age: an ergonomic analysis of work-related risks in a group of Swedish farmers aged 65 and over. Journal of Agromedicine (accepted for publication 20170509) [17] Lundqvist P. Ökad säkerhet inom jordbruket – interventioner och andra strategier. [Increased Safety in Agriculture - Interventions and Other Strategies] Rapport 2012:15. Swedish Work Environment Authority; 2012. (in Swedish) [18] Rautiainen R, Lehtola MM, Day LM, Schonstein E, Suutarinen J, Salminen S, Verbeek JH. Interventions for Preventing Injuries in the Agricultural Industry (Review). The Cochrane Library, 2009, Issue 3. [20]Collin McLaughlin A. Sprufera JF. Aging farmers are at risk for injuries and fatalities: how human-factors research and application can help. North Carolina Medical Journal, 2011;72(6): 481-483. [21] Swedish Work Environment Authority. Korta arbetsskadefakta, Jordbruk [Brief Statistics on Work-related Injuries in Agriculture]. Nr 2/2009. (in Swedish). [22] Swedish Work Environment Authority. Arbetsskador 2013 [Occupational Accidents and Work-related Diseases] Arbetsmiljöstatistik Rapport 2014:1. Stockholm: Swedish Work Environment Authority; 2014. (in Swedish). [23] Nilsson K. Why work beyond 65? Discourse on the decision to continue working or retire early. Nordic Journal of Working Life Studies 2012; 2(3):7-28 [24] Nilsson K. Rignell-Hydbom A. Rylander L. Factors influencing the decision to extend working life or to retire. Scand Journal of Work Environment & Health. 2011; 37(6):473-480. [25] Nilsson K. The Influence of Work Environmental and Motivation Factors on Seniors’ Attitudes to an Extended Working Life or to Retire. A Cross Sectional Study with Employees 55 - 74 Years of Age. Open Journal of Social Sciences, 2017;5:30-41 [26] Nilsson K. Pinzke S. Lundqvist P. Occupational Injuries to Senior Farmers in Sweden: Journal of Agricultural Safety & Health. 2010; 16(1):19-29.
略歴：Dr. Kerstin Nilssonは、公衆衛生分野で疫学のReader/Associate professor。スウエーデンのルンド大学医学部Lund University （Sweden）で労働衛生・環境衛生の研究者/講師として勤務し、また、Swedish University of Agricultural Sciences（スウエーデン 農業科学大学）でも労働科学や経済＆環境心理学部門に属している。彼女の主たる研究対象は「高齢の労働者」であり、全ての年代に おける持続可能な労働の理論モデルswAge-model（http://www.swage.org/）を立ち上げており、70もの論文を書いている。
51 IARM Keynote Lecture ②（Day 1）15 p.m.
World aging population, chronic diseases and impact of modifiable-metabolic risk factors Dr. Dimitris Tsoukalas（ギリシア） President of the European Institute of Nutritional Medicine, E.I.Nu.M.
For many decades, overpopulation was one of the major concerns of the modern world as a cause of struggle for resources in the next generations. This concept has been refuted based on birth rate facts and UN statistical data. The number of births per household decreases as we move to more educated and high- income countries. In fact, according to the U.N. Population Database, the Earth’s population will peak by the year 2100 at 11 billion people and then will start to decline. Attention has now been given to the demographic structures of the globe, as we move towards developed countries with an increasingly aging and shrinking population and growing but poor developing countries. This will lead to substantial production decrease in the developed countries, and increasing pressure from the poorer to move towards the developed world. However, the “aging society” threat can be prevented by maintaining healthy and productive populations at older ages. Over the last 150 years, life expectancy has increased more than twofold due to medical advances in treating and preventing acute and infectious diseases, the availability of clean drinking water, appropriate sewage systems, and basic hygiene education. We have managed to almost eliminate several deadly diseases and infections in all industrialized countries and most countries of the developing world. Chronic diseases are presently the leading cause of death and significantly deteriorate the quality of life worldwide. This modern pandemic accounts for the 70% of total global deaths. Most of these deaths, that is 80%, are preventable according to World Health Organization. Over 95% of the global population has one or more health problems raising many economic, demographic and sociological issues. Japan is the country with the highest rate of people 65 years or older in the world with 26.7%, while Greece ranks third with 21.39%. Historically, Greece has been one of the healthiest in Europe. However, socioeconomic factors and departure from a traditional healthy Mediterranean lifestyle had a significant impact on Greeks which rank among the first in childhood obesity worldwide. Although Mediterranean diet is generally accepted to be healthy, deviation from natural unprocessed foods has devastated the health status, particularly at younger ages. Income reduction is one of the leading factors of the massive rise of childhood and adolescent obesity, making fresh food unreachable thus opting for processed and low nutritional value food. Modifiable metabolic risk factors have a major impact on health with tobacco smoke, high systolic blood pressure, and diet being at the top of the list. As a result, chronic diseases incidence is linked with 91% of the total deaths with cardiovascular diseases, cancer, and neurological disorders being the leading causes. Chronic conditions are also the leading determinants of Disability-Adjusted Life Years (DALYs). Thus, more and more people live with one or more disability burden for extended periods of their lifetime. Health care can be substantially costly in long-term treatments as in the case of Non-Communicable Diseases (NCD), thus unreachable for low-resource people. Therefore, it is imperative to identify the cause of NCD and determine low cost and effective ways of prevention and treatment. Metabolomics, the science of studying metabolites, has emerged as a potent diagnostic tool seeking the metabolic cause of disease. High throughput analysis of metabolic signatures in blood and urine can provide an overview of the health state at a molecular level and reveal the impact of environmental factors on cells and eventually the body. This analysis can identify genetic-driven metabolic disorders but also detect minor metabolic disturbances which may or may not have developed to a disease. The causal approach to chronic diseases is novel in clinical diagnosis and personalized medicine. In addition to metabolic causes, chronic conditions are related to aging. Aging is not a simple wear out of the body but rather a multifactorial process where modifiable metabolic factors accelerate it. Telomeres
52 -that is the end part of chromosomes with the protective function of maintaining genomic stability- shorten as we get older playing a central role in the expression of aging. When telomeres reach a critically short length, cells become vulnerable to DNA damage and cell death. Distinct from genetic predisposition, nutrition, alcohol, tobacco, exercise and a wide range of lifestyle factors accelerate telomere shortening and aging while leading to the increased occurrence of chronic age-related diseases. Leucocyte telomere length measurement is strongly associated with known metabolic risk markers such as HDL cholesterol, triglycerides, insulin resistance, adiposity, cardiovascular disease, increased mortality, shorter lifespan and negative health effects in humans. Although life expectancy has an upward trend, the time we spend in good health declines. Emerging Systems Biology approaches, such as Metabolomics and Telomere Analysis, can provide valuable information on metabolic and genomic instability causes of chronic diseases, and lead to the development of effective interventions to improve longevity and decrease Disability-Adjusted Life Years.
Profile: President of the European Institute of Nutritional Medicine (E.I.Nu.M.) Metabolomic Medicine® Health Clinics for Autoimmune & Chronic Diseases, Metabolomic Medicine, Dr. Dimitris Tsoukalas, M.D. is the Director of Metabolomic Medicine Switzerland AG and President of the European Institute of Nutritional Medicine. Since 2007 he focuses on metabolomics analysis clinical application. Dr. Tsoukalas runs currently clinics that apply metabolomics analysis in addressing autoimmune and chronic diseases in Switzerland, Italy, and Greece. He is currently researching on telomere biology and metabolomics biomarkers use in clinical practice, collaborating with Prof. Aristides Tsatsakis and his team of the University of Crete School of Medicine, Greece.
53 IARM 基調講演 ②（第 1 日目）15 p.m.
世界の人口の高齢化、慢性疾患および 修正可能な代謝リスク因子の影響 Dr. Dimitris Tsoukalas（ギリシア） President of the European Institute of Nutritional Medicine, E.I.Nu.M.
何十年もの間、次世代の資源確保が難しくなる原因として、人口過剰は現代世界の主な懸念点の一つであっ た。しかし、この概念は実際の出生率（birth rate）と国連の統計データ（UN statistical data）に基づいて反 論されてきた。一世帯あたりの出生数は、教育水準と所得が高い国ほど減少する。実際、国連人口データベース （U.N. Population Database）によると、地球の人口は2100年までに110億人のピークに達し、その後減少し始 める。高齢化が進み人口が減少しつつある先進国（developed countries）と成長しつつあるが貧しい発展途上 国（developing countries）という構造が出来上がるにつれて、世界の人口構造（demographic structures）が 注目されるようになってきた。この構造は、先進国での大幅な生産減少と、貧しい人々が先進国に移動しようと する圧力の増加につながっている。しかし、高齢者が健康で生産的な人口層であり続けることにより「高齢化社 会 “aging society”」の脅威を防ぐことが出来る。 過去150 年間に、急性および感染性疾患の治療および予防における医学の進歩、清潔な飲料水の供給 （availability of clean drinking water）、適切な下水道システム（appropriate sewage systems）および基本的 な衛生教育（basic hygiene education）のおかげで平均余命が2倍以上に延びた。すべての工業国（industrialized countries）およびほとんどの発展途上国で、いくつかの致命的な病気や感染症はほぼ撲滅されている。 慢性疾患Chronic diseasesは現在、第一の死因であり、世界中の人々のクオリティ・オブ・ライフquality of lifeを著しく低下させている。この現代の流行病は、世界全体の死因の70%を占めている。世界保健機関（WHO） によると、これらの死亡の80%は防ぐことができる。世界人口の95%以上が1つ以上の健康問題を抱えており、 多くの経済的、人口統計的、社会的な問題を引き起こしている。 日本は、65歳以上の人口割合が26.7%と世界で最も高い国であり、ギリシャは21.39%で3位である。歴史的に、 ギリシャはヨーロッパ諸国の中で、最も健康な国の一つだった。しかし、社会的経済的要因（socioeconomic factors）と伝統的で健康的な地中海の生活様式（traditional healthy Mediterranean lifestyle）から離れたこと がギリシャ人に大きな影響を与え、小児肥満（childhood obesity）率が世界で最も高い国々の一つになっている。 地中海食（natural unprocessed foods）は一般に健康的であると考えられるが、自然で未加工の食品（natural unprocessed foods）を摂取しなくなったことは、特に若い人々の健康状態を悪化させている。小児期および青 年期の肥満が大幅に増加した主な要因の一つは収入の減少（Income reduction）であり、生鮮食品（fresh food） に手が届かないため、加工された栄養価の低い食品（processed and low nutritional value food）を選択するこ とになる。 修正可能な代謝リスク因子（Modifiable metabolic risk factors）のリストのトップにある、喫煙、高い収縮 期血圧、および食事内容は健康に大きな影響を与える。その結果、慢性疾患の発生は、心血管疾患・がん、およ び神経障害を主要な原因とする死者総数の91%と関連している。慢性疾患は、障害調整生存年数（Disability- Adjusted Life Years : DALYs）の主決定要因でもある。したがって、ますます多くの人々が、生涯にわたり1つ 以上の身体障害（disability burden）を持って生活している。非伝染性疾病（Non-Communicable Diseases: NCD）の場合は、治療が長期にわたると医療にかなり高いコストがかかり、収入の低い人々（low-resource people）には手が届かない。そのため、非伝染性疾病（NCD）の原因を特定し、低コストで効果的な予防法お よび治療法を見つけることが重要である。 メタボロミクス（Metabolomics）は、代謝産物を研究する科学であり、病気の代謝性原因を探る強力な診断 ツールとなっている。血液および尿中の代謝マーカーのハイスループット解析（High throughput analysis）に より、分子レベルでの大まかな健康状態が明らかになり、細胞そして最終的には身体に対する環境因子の影響が 明らかになる。この分析により、遺伝的要因による代謝障害（genetic-driven metabolic disorders）を同定で きるだけでなく、疾患に発展しているか否かにかかわらず、わずかな代謝障害も検出することができる。慢性疾 患に対する因果的アプローチ（causal approach）は、臨床診断およびオーダーメイド医療（personalized medicineI）において、今までにない新しい方法である。
54 代謝性原因に加えて、慢性疾患は加齢に関連している。加齢は身体の単純な摩耗（simple wear out of the body）ではなく、むしろ修正可能な代謝因子（modifiable metabolic factors）が促進する多因子プロセスであ る。染色体の末端部分にあり、ゲノムの安定性を維持する保護機能を持つテロメア（Telomeres）は、加齢につ れ短くなり、老化の発現において中心的な役割を果たす。テロメアが極めて短くなると、細胞はDNA損傷およ び細胞死に対して脆弱（vulnerable）になる。遺伝的素因とは異なり、栄養、アルコール、タバコ、運動、およ びさまざまな生活習慣因子がテロメア（telomere）の短縮および老化を加速し、加齢に伴う慢性疾患の発生を増 加させる。白血球テロメアの長さの測定値（Leucocyte telomere length measurement）は、例えばHDLコレ ステロール、中性脂肪、インスリン抵抗性、脂肪症（adiposity）、心血管疾患、死亡率の増加、ヒトにおける短 寿命および健康への悪影響などの既知の代謝リスクマーカーと強く関連している。 平均余命は上昇傾向にあるが、健康で過ごす時間は減少している。メタボロミクス（Metabolomics）やテロ メア解析（Telomere Analysis）などの新たなシステム生物学的手法は、慢性疾患の代謝不安定性およびゲノム 不安定性（metabolic and genomic instability causes of chronic diseases）に関する貴重な情報を提供し、寿 命を延ばし障害調整生存年数（Disability-Adjusted Life Years9 を減らすための効果的な介入方法の開発につな がると考えられる。
略歴：Dr. Dimitris Tsoukalas は、European Institute of Nutritional Medicine（E.I.Nu.M.）の理事長。同時に、Metabolomic Medicine Switzerland（スイス）AGの会長であり、European Institute of Nutritional Medicineの理事長でもある。2007年以来、 metabolomics analysis clinical applicationに焦点をあてて研究してきた。スイス、イタリア、ギリシアにおいて、自己免疫疾患や 慢性疾患の代謝解析研究を行っている。現在、ギリシアのクレタ大学医学部のAristides Tsatsakis教授のチームとtelomere biologyと metabolomics biomarkersに関する共同研究を行っている。
55 IARM Keynote Lecture ③（Day 1）17 p.m.
Providing Dementia Care in a rural region in Germany ‒ consequences of demographic change and concepts to encounter these Dr. René Thyrian（ドイツ） The research group leader at the German Center for Neurodegenerative Diseases (DZNE) in Rostock/ Greifswald, Germany
Background: Treatment and care need to focus on enabling people with dementia (PwD) to live at home as independently and as long as possible. Two approaches have been proposed in the past few years that focus on either (a) organizing providers and/ or stakeholders to use synergies, provide support and increase efficiency of the system, or (b) the individual level, providing person-centered care coordination. This article gives a summary about findings regarding Dementia Care Networks (DCN) and Dementia Care Management (DCM) and discusses implications/ consequences for translation into routine care. Main body: DCN have been established in Germany to provide support to PWD. In the years 2008-2010 and 2012-2015 the Federal Ministry of Health initiated a funding scheme, which aimed at providing scientific evidence about the coordination of ambulatory treatment and care in DCNs. There is sound scientific evidence, that DCN can be effective in improving treatment and care for PwD.. The analyses of different DCN networks throughout Germany have confirmed that DCN provide better health care for PwD and highlighted their importance as a health service infrastructure. The results contributed to a change in policy and social law which now can provide financial resources. To examine the efficacy of DCM, the “Dementia: life- and person-centered help in Mecklenburg- Western Pomerania (DelpHi)” trial was initiated. PWD were systematically identified in general practitioners´ offices and randomly assigned to either DCM or care as usual. Results indicate that systematic screening increased identification of people with dementia and thus integrated these people earlier into dementia care. DCM showed significant effects on medication, neuropsychiatric symptoms, caregiver burden and quality of life. Furthermore it was perceived as helpful and supportive by general practitioners (GP). Qualification and information technology support have been described as substantial for its delivery. Conclusions: Networking improves person-centered health outcomes, needs structural guidelines, distinct aims and sustainable finances. The DCM approach underlines that systematic identification of people and offering support for the service providers in primary care is of benefit to patients, their caregivers and the service providers. The underlying theme is that cooperation between research, service providers and legal representatives is essential to improve health care.
Profile: Dr. René Thyrian is a trained psychologist working as a research group leader at the German Center for Neurodegenerative Diseases (DZNE) in Rostock/ Greifswald. He has extensive experiences in population-based interventional research through studies in the field of addiction, life style, dementia and the health care system. Currently, he is focusing on diagnosis, treatment and care for people with dementia in underserved populations and rural populations. His main goal is to improve person-oriented outcomes by developing and evaluating concepts to implement into routine care. Dr. Thyrian is a member of the European network of researchers in psychosocial interventions INTERDEM. He has been involved in national and international research consortiums and has (co-) authored numerous scientific articles and chapters.
56 IARM 基調講演 ③（第 1 日目）17 p.m.
ドイツの地域における認知症ケアの提供 －人口構造の変化による影響とその対策－ Dr. René Thyrian（ドイツ） The research group leader at the German Center for Neurodegenerative Diseases (DZNE) in Rostock/ Greifswald, Germany
背景：認知症患者（people with dementia, PWD）の治療およびケアにおいては、患者ができる限り長く自宅で 自立して生活するための支援に重点を置くべきである。ドイツでは、ここ数年間、2通りの取り組み方が提案さ れてきた。すなわち（1）提供者（organizing providers）および／または利害関係者（stakeholders）を組織 して相乗効果を利用し（to use synergies）、サポートを提供しシステムの効率を向上させる（increase efficiency of the system）ことに重点を置く取り組みと、（2）個人レベルの、その人を中心としたケア（パーソン・セン タード・ケア: person-centered care coordination）に重点を置く取り組みである。本稿では、認知症ケアネッ トワーク（Dementia Care Networks : DCN）および認知症ケアマネジメント（Dementia Care Management : DCM）に関する知見を要約し、日常ケアに取り入れる場合の意義や影響について述べる。 本論：認知症ケアネットワーク（DCN）は認知症患者へのサポートを目的としてドイツで設立された。連邦保 健省（Federal Ministry of Health）は 2008～2010年および2012～2015年に、DCNによる外来治療およびケア 管理（ambulatory treatment and care）に関する科学的根拠（scientific evidence）を得ることを目的とした 資金助成計画を開始した。認知症の治療およびケアの向上にDCNが効果的であることを示す十分な科学的根拠 が得られている。ドイツ全国のさまざまなDCNについて分析した結果、DCNは認知症患者により良いヘルスケ アを提供していることが裏付けられ、健康サービスインフラ（health service infrastructure）としてのDCNの 存在意義が明らかにされた。この結果を受けて、政策および社会的法律が改正され、DCNに財源を供給できる ようになった。 また、認知症ケアマネジメント（DCM）の効果を検証するために、「認知症: メクレンブルク-西ポメラニア地 域における生活および人を中心とした支援（デルファイ法）」“Dementia: life- and person-centered help in Mecklenburg-Western Pomerania（DelpHi）”のタイトルで研究が行われた。一般開業医の診療所（general practitioners´ offices）で認知症患者を系統的に同定し、DCMまたは通常のケアに無作為に割り当てた。その結 果、系統的なスクリーニングによって認知症患者の同定が促進され、これらの患者が早期に認知症ケアを受けら れることがわかった。DCMは投薬治療、神経精神症状、介護者の負担、および生活の質に関して有意な効果を 示した。さらに、一般開業医general practitioners（GP）はDCMが有用で助けになると認識していた。DCM を実践するうえで、資格認定（qualification）および情報技術支援（information technology support）はかな りの役割を果たすと述べられている。 結論：ネットワーク形成により、人を中心としたケアの成果（person-centered health outcomes）が向上する。 また同時に、構造的指針、明確な目標、持続可能な財政制度が必要となる。DCMによる取り組みは、認知症患 者の系統的な同定および初期診療に関わるサービス提供者へのサポートが、患者、その介護者（caregivers）、お よびサービス提供者（service providers）にとっての有益であることを明確にした。根底にあるテーマとして、 ヘルスケアの向上には研究者、サービス提供者（research, service providers）、および法定代理人（legal representatives）の間の協力が不可欠である。
略歴：Dr. René Thyrianは、ドイツRostock/ Greifswald にあるNeurodegenerative Diseases（DZNE）ドイツ神経変性疾患セン ターの研究グループのリーダーであり、熟練した心理学者である。彼は、嗜癖（依存症）、生活習慣、認知症、医療制度の分野で、 population-basedの介入研究の経験が豊富である。現在、認知症を持つ人に対する診断、治療、ケアを、その行き届いていない地域と 農村（地方）地域にフォーカスを当て研究している。彼は、European network of researchers in psychosocial interventions INTERDEMのメンバーであり、国内外の研究コンソーシアムに広く参加している。
57 IARM Keynote Lecture ④（Day 1）18 p.m.
Aging and sustainable employment Prof. Clas-Håkan Nygård（フィンランド） Faculty of Social Sciences, Health, University of Tampere, Tampere, Finland
In many industrialized countries, there is a sharp increase of the ageing population due to a decrease in fertility and an increase in life expectancy. Due to that, the age dependency ratio rises and may cause increased economic burden on the productive part of the population. This is why most industrialized countries have made plans to extend working lives. A problem is that many people retire very early, long before they reach the official retirement age. A sufficient work ability is a requirement for a sustainable and prolonged employment. Recent research has revealed that work ability in average decrease with age, but necessarily not always linearly and so much that it end up with work disability. Several different trajectories exists when people are followed from their midlife in to old age (Bonsdorff, MB et al, 2011). A substantial proportion of individuals seems to maintain their work ability on a moderate level from midlife to old age, although work related factors like job strain might have harmful effects on work ability. Notable is that work demands, especially at midlife, very much predict further work ability and disability, health, functional ability, musculoskeletal disorders and even mortality (Ilmarinen et al, 1997, Bonsdorff, ME et al, 2011, Prakash et al 2017). Work-related factors as well as general lifestyle explain the declines and improvements in work ability during aging. The better work ability is, the later is the retirement. This makes work related factors including work ability, an important occupational and public health issue when the age of the population increases. Work ability is primarily a question of a balance between work and personal resources. Personal resources change with age whereas work demands may not change parallel to that, or only change due to globalization or new technology. There are two ways of promoting work ability. The first is to change the physical and psychosocial work environment and the other is to change (train) the employee. Interventions should preferably be problem-based, participative with employees, employers, occupational health and safety as well as human resource people involved. There are very few well-designed intervention studies (randomized and controlled) among older workers, aimed at promoting work ability (Cloostermans et al, 2014). However, according to a recent systematic review and meta- analysis, there is a small but insufficient evidence of a favorable effect of interventions to promote sustainable work ability among workers of different age (Oakman et al 2017). However, according to another review (Rongen et al 2013) there is an ample amount of studies among the general population showing positive general effects of work place health promotion. Although there is a need for well-designed intervention studies among ageing workers, promising interventions on multifactorial determinants including health and work related characteristics have been carried out, which shows good practices for promoting work ability among aging workers.
■ References von Bonsdorff, M.E., Kokko, K., Seitsamo, J., von Bonsdorff, M.B., Nygård, C.-H., Ilmarinen, J. Rantanen, T. Work strain in midlife and 28-year work ability trajectories (2011) Scand J Work, Environ Health, 37 (6), pp. 455-463. von Bonsdorff, M.B., Seitsamo, J., Ilmarinen, J., Nygård, C.-H., Von Bonsdorff, M.E., Rantanen, T. Work ability in midlife as a predictor of mortality and disability in later life: A 28-year prospective follow-up study (2011) CMAJ, 183 (4), pp. E235-E242. Cloostermans L, Bekkers, M, Uiters E, Proper, K. The effectiveness of interventions for ageing workers on (early) retirement, work ability and productivity: a systematic review (2014). Int Arch Occup Environ Health. DOI 10.1007/s00420-014-969-y
58 Ilmarinen J, Tuomi K, Klockars M. Changes in the work ability of active employees over an 11-year period (1997) Scand J Work Environ Health. 23: suppl 1:49-57. Oakman J, Neupane S, Proper KI, Kinsman N, Nygård C-H. Workplace interventions to improve work ability: A systematic review and meta-analysis of their effectiveness (2017) Scand J Work Environ Health, doi:10.5271/ sjweh.3685 K. C. Prakash, Neupane S, Leino-Arjas P, von Bonsdorff MB, Rantanen T,von Bonsdorff ME, Seitsamo J, Ilmar- inen J, and Nygård C-H. Work-Related Biomechanical Exposure and Job Strain as Separate and Joint Predictors of Musculoskeletal Dis- eases (2017) A 28-Year Prospective Follow-up Study. Am J Epidemiology, 10.1093/aje/kwx189 Rongen A, Robroek, S, Lenthe F, Burdorf A. Work place health promotion. A meta-analysis of effectiveness (2013). Am J Prev Med .44(4):406-415.
Profile: Dr Clas-Håkan Nygård is Professor in the Faculty of Social Sciences at the University of Tampere, Finland. He has extensive experiences in aging research through studies in ergonomics, work physiology as well as occupational gerontology. Dr Nygård is well published in the field of aging and work and has written numerous scientific articles and chapters. He is past president of the Finnish as well as the Nordic Ergonomics Societies and past secretary of the European Federation of Ergonomics Societies. For present he chairs the technical committee´s on Aging in the International Ergonomics Association (IEA) and the International Committee´ of Occupational Health (ICOH) and is also a fellow of IEA.
59 IARM 基調講演 ④（第 1 日目）18 p.m.
高齢化と持続可能な雇用 Prof. Clas-Håkan Nygård（フィンランド） Faculty of Social Sciences, Health, University of Tampere, Tampere, Finland
多くの工業国では、出生率の低下と平均寿命の伸びにより、高齢人口が急激に増加している。そのため、従属 年齢人口指数（age dependency ratio）が上昇し、総人口のうち生産年齢にある人々（productive part of the population）に課される経済的負担（economic burden）を増加させる要因となっている。このため、多くの工 業国は、就業期間（working lives）を延長する計画を立てている。しかし、問題は多くの人々が正式な退職年 齢（official retirement age）に達するずっと前に退職することにある。持続可能で長期的な雇用（sustainable and prolonged employment）のためには、十分な労働能力が必要である。最近の研究によると、年齢と共に平 均的な労働能力は低下するが、低下の傾向は必ずしも線形ではなく（not always linearly）、それは急激に低下 し、最終的には就労不能になることが明らかになった。中年から老年まで、人々が辿る過程には異なるいくつか の道筋（different trajectories）が存在する（Bonsdorff, MB et al., 2011）。職場ストレスのような仕事関連の 要因が、悪影響を及ぼしているかもしれないが、かなりの割合の人々が中年から老年まで適度なレベルの労働能 力を維持していると思われる。注目すべきは、特に中年層においては、労働需要（work demands）から、その 後の労働能力や就労不能、健康、機能的能力、筋骨格障害、さらには死亡率が予測できることである（Ilmarinen et al., 1997、Bonsdorff, ME et al., 2011、Prakash et al., 2017）。一般的な生活習慣と同様、仕事関連の要素 により、加齢の過程における労働能力の低下や向上について説明することができる。労働能力が高い（the better work ability）ほど退職は遅くなる（the later is the retirement）。人口の高齢化が進むと、労働能力を含む仕 事関連の要素が、重要な職業上や公衆衛生上の問題となる。 労働能力は、主に仕事と個人のリソースのバランス（balance between work and personal resources）の問 題である。個人のリソースは年齢とともに変化するが、労働需要は年齢と並行して変化するのではなく、グロー バリゼーション（globalization）や新技術（new technology）の登場に伴って変化する。労働能力を向上させ るには2つの方法がある。一つは、物理的・社会心理的職場環境（physical and psychosocial work environment） を変えること、もう一つは従業員の資質を変える（トレーニングする）ことである。介入は、就業者、雇用主に 加えて、労働衛生/安全（occupational health and safety）および人事に関係する人々（human resource people） が参加して、問題に基づいて（problem-based）行うべきである。高齢労働者の労働能力の促進を目的とするよ くデザインされた介入研究（well-designed intervention studies）（無作為および対照研究）は極めて少ない （Cloostermans et al., 2014）。しかし、最近の体系的なレビューとメタ分析（recent systematic review and meta- analysis）によれば、様々な年齢の労働者の持続可能な労働能力を促進する目的の介入において望ましい 効果があったという報告があるが、小規模で不十分（small but insufficient）である（Oakman et al., 2017）。 しかし、別のレビューによれば（Rongen et al., 2013）、一般集団（general population）における職場での健康 増進の一般的プラス効果（positive general effects of work place health promotion）を示す研究報告はたくさ んある。高齢労働者におけるよくデザインされた介入研究は必要とされているが、健康と労働に関係する特徴を 含む多因子決定要素（multifactorial determinants including health and work related characteristics）に関 する有望な介入は既に行われており、それらは高齢労働者の労働能力を向上させる優れた取り組み（good practices）となっている。
■ References von Bonsdorff, M.E., Kokko, K., Seitsamo, J., von Bonsdorff, M.B., Nygård, C.-H., Ilmarinen, J. Rantanen, T. Work strain in midlife and 28-year work ability trajectories (2011) Scand J Work, Environ Health, 37 (6), pp. 455-463. von Bonsdorff, M.B., Seitsamo, J., Ilmarinen, J., Nygård, C.-H., Von Bonsdorff, M.E., Rantanen, T. Work ability in midlife as a predictor of mortality and disability in later life: A 28-year prospective follow-up study (2011) CMAJ, 183 (4), pp. E235-E242.
60 Cloostermans L, Bekkers, M, Uiters E, Proper, K. The effectiveness of interventions for ageing workers on (early) retirement, work ability and productivity: a systematic review (2014). Int Arch Occup Environ Health. DOI 10.1007/s00420-014-969-y Ilmarinen J, Tuomi K, Klockars M. Changes in the work ability of active employees over an 11-year period (1997) Scand J Work Environ Health. 23: suppl 1:49-57. Oakman J, Neupane S, Proper KI, Kinsman N, Nygård C-H. Workplace interventions to improve work ability: A systematic review and meta-analysis of their effectiveness (2017) Scand J Work Environ Health, doi:10.5271/ sjweh.3685 K. C. Prakash, Neupane S, Leino-Arjas P, von Bonsdorff MB, Rantanen T,von Bonsdorff ME, Seitsamo J, Ilmar- inen J, and Nygård C-H. Work-Related Biomechanical Exposure and Job Strain as Separate and Joint Predictors of Musculoskeletal Dis- eases (2017) A 28-Year Prospective Follow-up Study. Am J Epidemiology, 10.1093/aje/kwx189 Rongen A, Robroek, S, Lenthe F, Burdorf A. Work place health promotion. A meta-analysis of effectiveness (2013). Am J Prev Med .44(4):406-415.
略歴：Dr Clas-Håkan Nygårdは、タンペレ大学（フィンランド）社会科学部門教授。人間工学ergonomics、労働生理学work physiology、職業老年学occupational gerontologyを通じて高齢化研究aging researchの著名な専門家である。高齢化と労働に関す る業績が多く、数多くの科学論文や著作がある。彼は、フィンランド及び北欧人間工学学会Finnish and Nordic Ergonomics Societies の前会長であり、ヨーロッパ人間工学学会・欧州連合の前事務総長でもある。現在、International Ergonomics Association（IEA） 国際人間工学協会（IEA）と、International Committee´ of Occupational Health（ICOH）国際労働衛生委員会（ICOH）の高齢 化検討委員会の議長である。
61 IARM Keynote Lecture ⑤（Day 2）9 a.m.
Workforce ageing an emerging challenge for Occupational Health and Safety and the Diagnosis and Prevention of Occupational Diseases. Claudio Colosio1, Michele Carugno2, Federica Masci1, Shengli Niu3 1Department of Health Sciences of the University of Milan,and International Centre for Rural Health of the S. Paolo Hospital of Milano, Italy（イタリア） 2Department of Clinical Sciences and Community Health, University of Milano, Italy 3International Labour Office, Geneva, Switzerland Introduction Life expectation is increasing in developed and industrialized countries but is still very low in developing, in-transition and underdeveloped countries. Figure 1 shows data on life expectancy at birth in selected countries representative of these four typologies. In this context, population ageing in the industrialized world has already become a fact and, according to various sources, the proportion of the ‘ageing part’ of these countries’ population will significantly increase over the coming years. This brings about relevant changes in the structure of the so-called “Age Pyramid”. Figures 2 and 3 show the distributions by age and gender of the EU and Japanese populations, respectively. Demographic changes and the resulting prolongations of retirement ages yield inherent challenges, as much for the employers as for the workers themselves (Feinsod, 2005). In particular, the composition of the workforce in these countries is quickly changing and the percentage of active aged workers is increasing, with workers being active even at the age of 70 years or more in some sectors (Figure 4). The example of Europe is shown in Figure 5. In this scenario, the intersection where employees’ ageing exerts its most profound effects is represented by employment and health, which, in turn, will influence not only healthcare and social security systems but also the national economies (Giannakouris, 2010; CEC, 2012). For example, it should be in the employers’ interest to foster the motivations and competencies of their staff and thus achieve the desired productivity levels. Similarly, it should be an ultimate concern of the employees to remain healthy, both mentally and physically, and thus upkeep their abilities to work. In other words, health and safety management can benefit both parties involved, provided that both sides know either how to work out the ‘right’ approaches or where to seek assistance from. In that regard, the capacities and experiences of occupational health professionals (OHPs), as well as of the medical specialists that the individuals most
Fig. 1: Life expectancy at birth (WHO, 2018)
62 in 2000 in 2050
EU25-total MEN WOMEN 85+ 80 - 84 75 - 79 70 - 74 65 - 69 60 - 64 55 - 59 50 - 54 45 - 49 40 - 44 35 - 39 30 - 34 25 - 29 20 - 24 15 - 19 10 - 14 5 - 9 0 - 4
,10 ,8 ,6 ,4 ,2 ,0 ,0 ,2 ,4 ,6 ,8 ,10 in 2000: 450,7 Total population (in millions) in 2050: 452,6 in 2000: 26 Old age dependency ratio (65+ in % 20-64) in 2050: 56 Source: Demographic and Labour Force database, used in OECD(2007), Society at a Glance: OECD Social Indicators 2006 Fig. 2: Population by age group, gender, in 2000 and 2050, as percentage of total population in each age group (Europe).
in 2000 in 2050
JAPAN MEN WOMEN 85+ 80 - 84 75 - 79 70 - 74 65 - 69 60 - 64 55 - 59 50 - 54 45 - 49 40 - 44 35 - 39 30 - 34 25 - 29 20 - 24 15 - 19 10 - 14 5 - 9 0 - 4
,10 ,8 ,6 ,4 ,2 ,0 ,0 ,2 ,4 ,6 ,8 ,10 in 2000: 126,9 Total population (in millions) in 2050: 100,6 in 2000: 28 Old age dependency ratio (65+ in % 20-64) in 2050: 72
Source: OECD, 2006. Fig. 3: Population by age group, gender, in 2000 and 2050, as percentage of total population in each group (Japan).
Source: OECD, 2014. Figure 4: Employment rate per age group (10-years categories).
63 Source: CEC, 2014.
Fig 5: Proportion (%) of workers aged 60 years and more in the active population in Europe
frequently encounter whilst being employed, seem of particular relevance (McDermott et al, 2010). The arising questions in this frame are whether OHPs are ready to meet the increased number of older workers, and whether systems and structures are ready to deal with their age-related health problems (Choon-Huat Kohm et al., 2006; ILO, 2012). Given all the above, dealing with age-related issues is becoming fundamental for both OHPs and managers. The condition for developing sound actions and interventions is represented by the availability of good knowledge, based on grounded evidence. Nonetheless, this knowledge is often missing and opinions not based on the evidence, as well as prejudices, are often present; even a precise definition of “aged worker” is missing. In this paper, we will propose a definition of “aged workers”, show specific health data regarding this working category, and recommend some specific actions to be taken.
Workforce ageing: some data The first step to achieve a good capacity of dealing with the aged workforce is represented by defining i) the specific age-related problems that are increasing with workforce ageing, and ii) the age one should reach to enter the group of “aged workers”. Probably, the best option is to include in this group the workers approaching to and exceeding traditional retirement age (60-65 years) (Farrow et al, 2012). It is worth reminding that the proportion of workers in this age range shows a continuous increase in the groups of paid employees in industrialized countries. The second arising question regards the levels of working capacity and performance of these workers. On this point, it should be underlined that the so-called “reduced performance” of aged workers is much more a myth rather than a scientific evidence. A study conducted in the UK showed that people working beyond the state pension age had higher education levels and better health, compared with retired workers of the same age. Epidemiological data suggest that one of the main risks associated with physical decline is age-related hearing loss (Farrow et al, 2012), even if this does not represent a source of severe reduction of the working capacities (except for the most serious cases). The main determinants of reduced working capacities in aged workers are shown in Figure 6, in details: musculoskeletal disorders, hypertension, metabolic diseases, respiratory disease, and psychological disorders (ISTAT, 2014). It should also be recalled that the percentage of subjects carrying associated chronic conditions increases with the age (Ilmarinen, 1999; Giannakouris, 2012). The third question that arises regarding health and safety of the aged workers is whether there is an increased risk of occupational diseases and accidents in workers this group. Data collected in Italy show that 59.9% of the occupational diseases reported in 2015 regard workers in the age range 50-64. On the other hand, the proportion of reports regarding workers aged more than 64 is negligible (INAIL, 2017), even if workers in this age range represent a very small proportion of the total workforce. In addition,
64 No Type of Chronic disease General popula on People aged ≥ 65 years 2005 2013 2005 2013 1 Arthrosis, Arthri s 19.8 16.2 57.1 49.4 2 Hypertension 14.5 17.1 40.3 48.4 3 Osteoporosis 5.4 6.8 17.5 24.2 4 Diabetes 4.9 5.6 14.8 17.6 5 Other heart diseases 3.5 4.0 11.9 13.1 6 Anxiety or Depression 5.5 5.5 12.2 13.0 7 Chronic Bronchi s, Emphysema 5.1 3.9 15.5 11.9 8 Headache and Recurrent Migraine 7.8 10.8 8.3 11.0 9 Allergic diseases 10.6 13.7 8.0 10.4 10 Depression - 4.3 - 10.1 Source: ISTAT, 2014.
Figure 6: Prevalence of chronic diseases in the Italian general population (the “top ten” conditions) and comparison with people aged ≥ 65 years.
Age class 2009 2010 2011 2012 2013 15 - 34 yrs 19,33 19,28 19,58 18,96 19,03 35 a 49 yrs 37,10 36,98 36,02 35,39 34,47 50 - 64 yrs 31,57 31,80 32,39 33,69 34,08 65 yrs and above 12,00 11,93 12,01 11,96 12,42 Figure 7: Accidents reported in Italy in the agricultural sector per age class (INAIL, 2014)
most of the occupational diseases observed in the industrialized countries have quite long induction periods or latencies. Therefore, elderly workers are without a doubt the group in which exposures that occurred during life are able to bring about their effects. As for vulnerability to accidents, data collected in Italy in the agricultural sector (where aged workers are strongly represented) suggest that a proportion close to 50% of all the observed accidents involves workers aged 50 years or more (Figure 7). These data confirm that, even though the physiological mental decline associated with normal ageing seldom impacts on performance in most work (until age 70), jobs requiring fast reactions or physical strength deserve particular attention when assigned to the aged workers (Farrow et al, 2012).
Conclusions and recommendations Despite the absence of a universally accepted definition of “aged workers”, we might conclude to define as “aged” all workers remaining active after the traditional retirement age (60-65 years in the so called “developed world”). This applies well despite the fact that in some official EU publication the term “aged” is applied to workers older than 45 (Boukal et al, 2005). This latest definition has the disadvantage that retirement age may vary among different countries, but has also the advantage of linking the concept of ageing with local situations. In particular, in developing and in-transition countries, where working conditions are peculiar and life expectation is shorter, people age earlier than in industrialized countries and the whole process develops in advance. Based on UNFPA estimates, whereas one out of every 10 persons in the world today is aged 60 or more, this figure is expected to rise to one out of every eight persons by 2020; in industrialized countries, such as most European ones, the 45-64 age group is expected to represent almost half of the working population (UNFPA, 2012). This means that dealing with the problems of the elderly and promoting their optimal work placement will become an objective that cannot be given up. In addition, older workers are valuable assets for experience, knowledge and skills and may greatly contribute to a sound development of the enterprises and their related activities. According to the EU, a sustained growth in longevity means that people have greater opportunities to fulfil their potential over a longer life (CED, 2012). Based on the
65 available data, the occupational prevention for the elder workers should focus mainly on the activities. This means that occupational health and safety should deal in the future with a “Geriatric Perspective” (Choon-Huat Koh, 2006). The only activities which should not be assigned to older workers are those which require fast reactions or physical strength (Farrow et al, 2012), together with those which may accelerate the ageing process, such as manual handling of heavy loads, excessive noise exposure, atypical working hours, or excessive organizational change. Not engaging these workers in activities requiring fast reaction times is a proper tool to protect them from the risk of accidents, apparently increased in this age group. These recommendations are particularly important in risky sectors such as agriculture, construction, mining and, for several aspects, also the informal sector. In any case, the occupational health physician and the prevention personnel should participate in a process addressed at creating working conditions adequate for aged workers. It should also be recalled that among aged workers some diseases such as hypertension, metabolic diseases, respiratory diseases, and psychological disorders, often present as comorbidities, are highly prevalent (Illmarinen 2006; Illmarinen 2012). This makes it fundamental to offer them specific health promotion programmes. Note that this preventive action well applies with a modern conception of occupational health, where a broader role of the occupational health physician is hoped for, well above the limited and specific task of providing health surveillance for workplace occupational risk factors. Finally, it should also be taken into account that aged workers present higher risks of suffering from occupational diseases with long latency or induction times, thus following remote exposures. In this context, it is important to underline that aged workers cannot be involved in an occupational health surveillance only limited to workplace risks: as a matter of fact, collecting an accurate personal history might point out the presence of past (or even remote) exposures, which might produce an effect even decades after their end. This is the case of occupational neoplasms, but also of other diseases (e.g. pulmonary fibrosis, allergies, musculoskeletal disorders, noise-induced hearing loss, diseases due to vibrations) that may be reported even several years after the end of the causal exposure, either because of a delayed onset or because of a delayed diagnosis. It is worth to mention that the new “ILO List of Occupational Diseases”, approved by a Tripartite meeting in 2010, represents a unique and irreplaceable tool to identify the various nosological entities of interest and set priorities for prevention. Moreover, an international working group of experts is currently engaged in the preparation of a document of diagnostic and exposure criteria, which will be soon available for occupational physicians, medical doctors, stakeholders and the larger public. An adequate training and education of all these subjects, from those in charge of taking care of the aged workers to the workers themselves, represents the necessary condition to promote a safe prevention in this high concern group.
■ References Boukal, C. and Meggeneder, O. Healthy work in an ageing Europe: a European collection of measures for promoting the health of ageing employees at the workplace. Frankfurt am Main: Mabuse- Verlag; 2005. Choon-Huat Koh G. Koh D. Occupational health for an ageing workforce: do we need a geriatric perspective? Journal of Occupational Medicine and Toxicology, 2006, 1:8 (doi:10.1186/1745-6673-1-8), Retrieved on October 3, 2012 from: http://www.occup-med.com/content/1/1/8 Commission of European Communities (CEC). The European Economic and Social Committee and the Committee of the Regions. Communication from the Commission to the Council, the European Parliament. White Paper Together for Health: A Strategic Approach for the EU 2008-2013. Increasing the employment of older workers and delaying the exit from the labour market. Commission of the European Communities, Brussels 03.03.2004, COM (2004) 146 Final. Retrieved on October 8, 2012 from: http://eur-lex.europa.eu/ LexUriServ/LexUriServ.do?uri=COM:2004:0146:FIN:EN:PDF Commission of the European Communities (CEC), Brussels, 23.10.2007. COM(2007) 630 final, Retrieved on October 08, 2012 from: http://ec.europa.eu/health/archive/ph_overview/documents/strategy_wp_en.pdf Farrow A, Reynolds F; Health and safety of the older worker, Occupational Medicine, Volume 62, Issue 1, 1 January 2012, Pages 4–11, https://doi.org/10.1093/occmed/kqr148 Feinsod, R. Business case for workers aged 50+: planning for tomorrow's talent needs (...): a report for AARP. Washington, DC: AARP; 2005
66 Giannakouris K. Population and social conditions. Eurostat - Statistics in focus 1/2010. European Union 2010. Retrieved on October 8, 2012 from: http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-SF-10-001/EN/KS- SF-10-001-EN.PDF Ilmarinen J. Ageing Workers in the EU – Status and promotion of work ability, employability and employment. Helsinki: Finnish Institute of Occupational Health, Ministry of Social Affairs and Health, Ministry of Labour, 1999 Ilmarinen J. Aging workers. Occup Environ Med 2001, 58:546 (doi:10.1136/oem.58.8.546) Retrieved on October 08, 2012 from: http://oem.bmj.com/content/58/8/546.full.html Ilmarinen J. The ageing workforce – challenges for occupational health. Occup. Med. (Lond) 2006, 56:362-4 (doi:10.1093/occmed/kq1046) Retrieved on October 3, 2012 from: http://occmed.oxfordjournals.org/ International Labour Office (ILO). Young and older workers, two sides of the same coin. ILO News. Retrieved on October 08, 2012 from: http://www.ilo.org/global/about-the-ilo/newsroom/comment-analysis/WCMS_190891/lang- -en/index.htm Istituto Italiano di Statistica (ISTAT). Tendenze demografiche s nuove sfide per il welfare, Capitolo 4. ISTAT, 2014. Istituto Italiano per l’assicurazione degli Infortuni e malattie professionali (INAIL). https://www.inail.it/cs/ internet/home.html Date of last access: 21/01/2018. McDermott, H.J. et al. Developing occupational health services for active age management. Occupational Medicine (2010), 60(3): 193-204. OECD (2014), “Employment rates by age group”, in OECD Factbook 2014: Economic, Environmental and Social Statistics, OECD Publishing, Paris. DOI: http://dx.doi.org/10.1787/factbook-2014-53-en Organization for Economic Cooperation and development OECD. Society at a Glance OECD SOCIAL INDICATORS 2006. EDITION ISBN-92-64-028196-X © OECD 2006. United Nations Population Fund (UNFPA). Ageing in the Twenty-First Century: A Celebration and A Challenge. Published by the United Nations Population Fund (UNFPA), New York, 2012. Registered charity no. 288180. ISBN 978-0-89714-981-5. World Health Organization (WHO). Global Health Observatory (GHO) data. Life expectancy. http://www.who.int/ gho/mortality_burden_disease/life_tables/situation_trends_text/en/ Date of last access: 21/01/2017.
Profile: Prof. Claudio Colosio is a medical doctor and PhD in occupational health and safety. He is currently Associate Professor of Occupational Health at the Department of Health Sciences of the University of Milan and Scientific Coordinator of the International Centre for Rural Health of the Hospital San Paolo of Milano, World Health Organization Collaborating Centre in Occupational Health. His main research interests are in the field of Occupational Health and Rural and Agricultural Medicine. Additional research interests are occupational toxicology, with a particular attention for pesticides and pesticide related issues. Prof. Colosio has participated, both as a component and as Coordinator, in several projects of national and international research, and currently is engaged in collaborative EU research projects and Tempus programmes. He has been member of the Advisory Committee on Pesticides of the Italian Ministry of Health, of the Working Group "Farmworkers and pesticides" of ANSES (Agence Nationale Française de Sécurité Sanitaire de l'alimentation, de l'environnement et du Travail). He is past president and secretary of the Scientific Committee on Rural Health of the International Commission of Occupational Health (ICOH) and Vice- President of the International Association of Agricultural Medicine and Rural Health. One of the main activities he is nowadays coordinating is the definition of experiences addressed at improving the access into health care systems of disadvantaged populations, in particular living and working in rural and remote areas. In this field, he has participated in 2011 in the Den Haag global Conference “Connecting Health and Labour. What Role for Occupational Health in Primary Health Care” and in 2014 in the international Consultation “Caring for all working people: Interventions, Indicators and Service Delivery” organized by WHO in Senman (Islamic Republic of Iran). He is the author of over 100 papers published on peer reviewed journals, chapters of textbooks and author of more than 200 presentations at national and international Congresses. He acted as teacher in national and international training courses and is holder of occupational medicine and health teaching in undergraduate and postgraduate courses in Occupational Medicine, as well as refreshing courses for GPs.
67 IARM 基調講演 ⑤（第 2 日目）9 a.m.
労働人口の高齢化：労働衛生と安全、職業病の診断と 予防に対する新しい挑戦 Claudio Colosio1, Michele Carugno2, Federica Masci1, Shengli Niu3 1Department of Health Sciences of the University of Milan,and International Centre for Rural Health of the S. Paolo Hospital of Milano, Italy（イタリア） 2Department of Clinical Sciences and Community Health, University of Milano,, Italy 3International Labour Office, Geneva, Switzerland
緒言 平均余命は先進工業国では延びているが、発展途上国、移行国、未開発国ではいまだに非常に低い。図1に、 これら4類型の代表的な国における出生時平均余命データを示す。先進工業国における人口の高齢化はすでに現 実となっており、さまざまな情報源によると、これらの国々の「高齢者」人口の割合は今後数年で著しく増加す る。これにより、いわゆる「人口ピラミッド」の構造に変化が生じる。図2と図3に、EUと日本の年齢および性 別による人口分布をそれぞれ示す。人口構造の変化とそれに伴う退職年齢の引き上げにより、雇用主のみならず 労働者自身も特有の課題に直面している（Feinsod, 2005）。特に、これらの国における労働人口の構成は急速に 変化しており、現役の高齢労働者の割合は増加している。70歳以上で現役の労働者がいるセクターもある（図 4）。ヨーロッパの例を図5に示す。この場合、労働者の高齢化による影響が最も大きく表れるのは雇用と健康の 関係であり、それは医療や社会保障制度だけでなく国民経済にさえ影響を及ぼす（Giannakouris, 2010；CEC, 2012）。たとえば雇用主は、スタッフの意欲や能力を高めて、望ましい生産性レベルを達成することに関心があ る。同様に、労働者にとって一番大切なのは、精神的にも身体的にも健康を保ち、働く能力を維持することであ る。つまり、安全衛生管理は双方の当事者にとって利益となる。ただし、双方とも「正しい」取り組みを実行す る方法や支援を求められる場所を知っていることが前提である。これに関して言えば、雇用されている人と接す る機会の多い、労働衛生および医療の専門家が持つ能力や経験は特に関連があると思われる（McDermott et al, 2010）。ここで、労働衛生の専門家は高齢労働者の増加に対応する用意があるのか、また、加齢に伴う健康問題 に対処できるように制度や構造が整備されているのか、という問が生じる（Choon-Huat Kohm et al, 2006； ILO, 2012）。上記の点すべてを考慮すると、加齢に伴う問題は労働衛生の専門家と経営者の双方にとって基本 的な問題となってきている。合理的な行為および介入を発展させるための条件は、確固たる証拠に基づく知識が 得られることである。それにもかかわらず、この知識が欠けている場合は多く、証拠に基づかない意見や先入観 がよく見られる。「高齢労働者」の正確な定義さえない。
図1: 各国の平均寿命（WHO, 2018）
68 in 2000 in 2050
EU25-total MEN WOMEN 85+ 80 - 84 75 - 79 70 - 74 65 - 69 60 - 64 55 - 59 50 - 54 45 - 49 40 - 44 35 - 39 30 - 34 25 - 29 20 - 24 15 - 19 10 - 14 5 - 9 0 - 4
,10 ,8 ,6 ,4 ,2 ,0 ,0 ,2 ,4 ,6 ,8 ,10 in 2000: 450,7 Total population (in millions) in 2050: 452,6 in 2000: 26 Old age dependency ratio (65+ in % 20-64) in 2050: 56 Source: Demographic and Labour Force database, used in OECD(2007), Society at a Glance: OECD Social Indicators 2006
図2: ヨーロッパの男女別・年齢別の人口数の比較 in 2000 and 2050
in 2000 in 2050
JAPAN MEN WOMEN 85+ 80 - 84 75 - 79 70 - 74 65 - 69 60 - 64 55 - 59 50 - 54 45 - 49 40 - 44 35 - 39 30 - 34 25 - 29 20 - 24 15 - 19 10 - 14 5 - 9 0 - 4
,10 ,8 ,6 ,4 ,2 ,0 ,0 ,2 ,4 ,6 ,8 ,10 in 2000: 126,9 Total population (in millions) in 2050: 100,6 in 2000: 28 Old age dependency ratio (65+ in % 20-64) in 2050: 72
Source: OECD, 2006. 図3: 日本の男女別・年齢別の人口数の比較 in 2000 and 2050.
Source: OECD, 2014.
図4: 各国の就業者比率（10-years categories）．
69 Source: CEC, 2014.
図5: ヨーロッパの生産人口の中で、60歳以上の労働者の割合（%）
本稿では、「高齢労働者」の定義を提案し、この労働区分に関する具体的な健康データを示し、いくつかの具 体的な対策を提言する。
労働人口に関するデータ（Workforce ageing: some data） 労働人口の高齢化に対応する十分な能力を得るための第一歩は、1）労働人口の高齢化に伴い増加する加齢に 関連する具体的な問題、および2）「高齢労働者」グループに分類されるようになる年齢を定義することである。 恐らく、従来の退職年齢に近い、またはその年齢を超えた労働者（60～65歳）を「高齢労働者」グループに分 類するのが一番良い（Farrow et al, 2012）。先進工業国の賃金労働者グループの中で、この年齢層の労働者の割 合は増え続けていることを覚えておきたい。 次に、高齢労働者の作業能力および職務遂行能力の水準に関する質問が生じる。この点で、高齢労働者のいわ ゆる「職務遂行能力の低下」が、科学的証拠に基づくというよりは俗説にすぎないことを強調する必要がある。 英国で行われた研究によると、公的年金受給年齢を超えても働いている人々は、同年齢で退職している人々より も教育レベルが高く、健康状態も良かった。疫学的データによると、（最も重症の場合を除き）聴力低下が深刻 な作業能力低下の原因となるわけではないとしても、身体的衰えに伴う主なリスクの1つは、加齢による聴力低 下である（Farrow et al, 2012）。高齢労働者の作業能力低下の主な決定因子を図6に詳しく示す。筋骨格疾患、 高血圧、代謝性疾患、呼吸器疾患、精神的疾患が挙げられる（ISTAT, 2014）。慢性疾患を合併する患者の割合 も年齢と共に増えることを覚えておきたい（Ilmarinen, 1999；Giannakouris, 2012）。 高齢労働者の衛生安全に関連して生じる3つ目の質問は、高齢労働者の職業病や労働災害のリスクが高まるの か否かである。イタリアのデータによると、2015年に報告された職業病のうち59.9%は50～64歳の労働者に関 するものであった。一方、64歳以上の労働者に関する報告の割合は、この年齢層の労働者が総労働人口に対して ごくわずかであることを考慮しても、無視できるほど小さい（INAIL, 2017）。さらに、先進工業国における職 業病の多くは、誘導期または潜伏期が極めて長い。高齢労働者は間違いなく、生涯中のばく露による影響が表れ やすいグループである。労働災害の起きやすさについては、イタリアで高齢労働者の存在感が著しい農業セク ターで集めたデータによると、労働災害全体のうち50%近くに50歳以上の労働者が関係していた（図7）。こ れ ら のデータから、ほとんどの職種で（70歳までは）通常の加齢に伴う生理的・精神的衰えが職務遂行能力に影響す ることはあまりないものの、素早い反応や体力が求められる仕事を高齢労働者に割り当てる際は特別な注意が必 要であることが確認された（Farrow et al, 2012）。
結論と提言 世界的に受け入れられている「高齢労働者」の定義はないが、従来の退職年齢（いわゆる「先進国」では60～ 65歳）を超えて現役で働く労働者はすべて「高齢」と定義できるであろう。EUの公式刊行物の中には「高齢」 という語を45歳以上の労働者に適用しているものもあるが（Boukal et al, 2005）、上述の定義のほうがよく当 てはまる。この最新の定義のデメリットは退職年齢が国によって異なることだが、高齢化の概念を現地の状況と 関連付けられるというメリットもある。特に、労働環境が特異で平均余命の短い発展途上国や移行国の人々は先 進工業国の人々よりも早く老化し、すべての過程がより早く進行する。
70 No Type of Chronic disease General popula on People aged ≥ 65 years 2005 2013 2005 2013 1 Arthrosis, Arthri s 19.8 16.2 57.1 49.4 2 Hypertension 14.5 17.1 40.3 48.4 3 Osteoporosis 5.4 6.8 17.5 24.2 4 Diabetes 4.9 5.6 14.8 17.6 5 Other heart diseases 3.5 4.0 11.9 13.1 6 Anxiety or Depression 5.5 5.5 12.2 13.0 7 Chronic Bronchi s, Emphysema 5.1 3.9 15.5 11.9 8 Headache and Recurrent Migraine 7.8 10.8 8.3 11.0 9 Allergic diseases 10.6 13.7 8.0 10.4 10 Depression - 4.3 - 10.1 Source: ISTAT, 2014.
図6: イタリアの一般人口に占める慢性疾患の罹患率（トップ10）と65歳以上人口との比較
Age class 2009 2010 2011 2012 2013 15 - 34 yrs 19,33 19,28 19,58 18,96 19,03 35 a 49 yrs 37,10 36,98 36,02 35,39 34,47 50 - 64 yrs 31,57 31,80 32,39 33,69 34,08 65 yrs and above 12,00 11,93 12,01 11,96 12,42
図7: イタリアの農業部門での事故（年齢別）の報告数（INAIL, 2014）
国連人口基金（UNFPA）の推定によると、現在は世界人口の10人に1人が60歳以上であるが、ヨーロッパの 多くの国を含む先進工業国では2020年までにこの数字が8人に1人になり、45～64歳の年齢層が世界の労働人口 の約半分を占めるようになると予想される（UNFPA, 2012）。つまり、今後、高齢者の問題に対応し最適な職業 配置を促進することは放棄するわけにはいかない目標になる。さらに、高齢労働者は経験、知識、技術の点で貴 重な人材であり、企業の健全な発展および関連する活動に大きく貢献する可能性がある。EUによると、寿命の 持続的な延びは、人々がより長い人生の中で自分の可能性を発揮する機会の広がりを意味する（CED, 2012）。 入手できるデータからすると、高齢労働者の職業病の予防においては、主に作業に焦点を合わせるべきである。 つまり、今後、労働安全衛生は「老年医学的観点」で取り組む必要がある（Choon-Huat Koh, 2006）。高齢労 働者に割り当てるべきでない数少ない仕事は、素早い反応や体力が求められる作業（Farrow et al, 2012）、お よ び、重い荷物を手で運ぶ、過剰な騒音への暴露、変則的な勤務時間、激しい組織変動など、老化の過程を早める 仕事である。素早い反応が求められる作業を割り当てないことは、この年齢層で高くなると思われる事故のリス クから高齢労働者を保護するための適切な方法である。農業、建設業、鉱業、一部のインフォーマル・セクター など危険性の高いセクターでは、これらの提言が特に重要になる。いずれにしても、労働衛生医および予防担当 者が参加する取り組みを通じて、高齢労働者にとって適切な労働環境を作り上げていく必要がある。 また、高齢労働者は、高血圧、代謝性疾患、呼吸器疾患、精神的疾患などの併存疾患を有している場合が多い ことを覚えておきたい（Illmarinen 2006；Illmarinen 2012）。そのため、具体的な健康増進プログラムの提供 は欠かせない。このような予防策は現代的な労働衛生の概念によく当てはまる。すなわち、労働衛生医には、仕 事場における職業上の危険因子の調査という限定的で特定的な任務よりもはるかに広い役割が期待されている。 最後に、高齢労働者は、ずっと以前の暴露を原因とした、誘導期または潜伏期の長い職業病にかかるリスクが 高いことも考慮する必要がある。ここで強調したい点として、高齢労働者の場合、仕事場でのリスクに限定した 労働衛生調査では不十分である。実際、正確な経歴を調べるなら、過去に（またはずっと以前に）暴露があり、 暴露の終了後何十年も経ってから影響が表れたことがわかる場合もある。職業に関連した悪性新生物 （occupational neoplasms）がこれに当てはまるが、他の疾患（肺線維症、アレルギー、筋骨格疾患、騒音によ る聴力低下、振動による疾患など）でも、発病または診断が遅れたために、原因となる暴露の終了から数年後に 報告される場合がある。2010年の3者会議で承認された新しい「国際労働機関（ILO）による職業性疾病のリス ト」では、関係するさまざまな疾病分類学的カテゴリーを特定し予防の優先順位を定めるための、他では得がた
71 い独自の方法が説明されていることに触れておきたい。加えて、国際的な専門家作業部会が「診断基準」および 「暴露基準」を現在作成中であり、まもなく労働衛生医、医師、利害関係者、一般市民にも入手できるようにな る。関心の的となっている高齢労働者の安全対策を促進するには、高齢労働者の管理にあたる責任者から労働者 自身にいたるまで、すべての関係者が適切なトレーニングや教育を受けることが必要である。
■ References 1. Boukal, C. and Meggeneder, O. Healthy work in an ageing Europe: a European collection of measures for promoting the health of ageing employees at the workplace. Frankfurt am Main: Mabuse- Verlag; 2005. 2. Choon-Huat Koh G. Koh D. Occupational health for an ageing workforce: do we need a geriatric perspective? Journal of Occupational Medicine and Toxicology, 2006, 1:8 (doi:10.1186/1745-6673-1-8), Retrieved on October 3, 2012 from: http://www.occup-med.com/content/1/1/8 3. Commission of European Communities (CEC). The European Economic and Social Committee and the Committee of the Regions. Communication from the Commission to the Council, the European Parliament. White Paper Together for Health: A Strategic Approach for the EU 2008-2013. Increasing the employment of older workers and delaying the exit from the labour market. Commission of the European Communities, Brussels 03.03.2004, COM (2004) 146 Final. Retrieved on October 8, 2012 from: http://eur-lex.europa.eu/ LexUriServ/LexUriServ.do?uri=COM:2004:0146:FIN:EN:PDF 4. Commission of the European Communities (CEC), Brussels, 23.10.2007. COM(2007) 630 final, Retrieved on October 08, 2012 from: http://ec.europa.eu/health/archive/ph_overview/documents/strategy_wp_en.pdf 5. Farrow A, Reynolds F; Health and safety of the older worker, Occupational Medicine, Volume 62, Issue 1, 1 January 2012, Pages 4–11, https://doi.org/10.1093/occmed/kqr148 6. Feinsod, R. Business case for workers aged 50+: planning for tomorrow's talent needs (...): a report for AARP. Washington, DC: AARP; 2005 7. Giannakouris K. Population and social conditions. Eurostat - Statistics in focus 1/2010. European Union 2010. Retrieved on October 8, 2012 from: http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-SF-10- 001/EN/KS-SF-10-001-EN.PDF 8. Ilmarinen J. Ageing Workers in the EU – Status and promotion of work ability, employability and employment. Helsinki: Finnish Institute of Occupational Health, Ministry of Social Affairs and Health, Ministry of Labour, 1999 9. Ilmarinen J. Aging workers. Occup Environ Med 2001, 58:546 (doi:10.1136/oem.58.8.546) Retrieved on October 08, 2012 from: http://oem.bmj.com/content/58/8/546.full.html 10. Ilmarinen J. The ageing workforce – challenges for occupational health. Occup. Med. (Lond) 2006, 56:362-4 (doi:10.1093/occmed/kq1046) Retrieved on October 3, 2012 from: http://occmed.oxfordjournals.org/ 11. International Labour Office (ILO). Young and older workers, two sides of the same coin. ILO News. Retrieved on October 08, 2012 from: http://www.ilo.org/global/about-the-ilo/newsroom/comment-analysis/WCMS_190891/ lang--en/index.htm 12. Istituto Italiano di Statistica (ISTAT). Tendenze demografiche s nuove sfide per il welfare, Capitolo 4. ISTAT, 2014. 13. Istituto Italiano per l’assicurazione degli Infortuni e malattie professionali (INAIL). https://www.inail.it/cs/ internet/home.html Date of last access: 21/01/2018. 14. McDermott, H.J. et al. Developing occupational health services for active age management. Occupational Medicine (2010), 60(3): 193- 204. 15. OECD (2014), “Employment rates by age group”, in OECD Factbook 2014: Economic, Environmental and Social Statistics, OECD Publishing, Paris. DOI: http://dx.doi.org/10.1787/factbook-2014-53-en 16. Organization for Economic Cooperation and development OECD. Society at a Glance OECD SOCIAL INDICATORS 2006. EDITION ISBN-92-64-028196-X © OECD 2006. 17. United Nations Population Fund (UNFPA). Ageing in the Twenty-First Century: A Celebration and A Challenge. Published by the United Nations Population Fund (UNFPA), New York, 2012. Registered charity no. 288180. ISBN 978-0-89714-981-5. 18. World Health Organization (WHO). Global Health Observatory (GHO) data. Life expectancy. http://www.who. int/gho/mortality_burden_disease/life_tables/situation_trends_text/en/ Date of last access: 21/01/2017.
72 略歴：Dr.クラウデイオ・コロシオは、労働安全衛生を専門とするMD、PhDである。現在、ミラノ大学（イタリア）の健康科学・労働 衛生分野のAssociate Professor、また、WHOとコラボしているSan Paolo病院のInternational Centre for Rural HealthでScientific Coordinatorを勤めている。彼の主たる研究分野は、労働衛生と地域医療・農村医学である。国内・国外の施設と多くのコラボをこな しており、現在、EU research projects and Tempus programにも参加している。彼は、イタリア厚生省の農薬中毒部会のアドバイ ザーであり、ANSES（Agence Nationale Française de Sécurité Sanitaire de l'alimentation, de l'environnement et du Travail） の「農業従事者と農薬中毒」のワーキンググループの一員である。また、WHOのInternational Commission of Occupational Health （ICOH）の前会長であり、International Association of Agricultural Medicine and Rural Health（IARM）の副会長である。彼の peer reviewedジャーナルの論文は100以上、国内・国外の学会発表は200以上を数える。
73 IARM Keynote Lecture ⑥（Day 2）10 a.m.
Aging Serbian rural population: defining the health care needs and searching for solutions Prof. Petar Bulat（セルビア） University of Belgrade Faculty of Medicine & Serbian Institute of Occupational Health, Belgrade, Serbia
Introduction/Background Serbia facts Serbia is a relatively small country located on the Balkan Peninsula, in South East Europe. The surface of Serbia is 88,361 km2 (34,116 sq mi), with 19,194 km2 of arable land (24.8%) and 19,499 km2 of forests (25.2%). The terrain of Serbia ranges from rich, fertile plains of the northern region (Vojvodina), limestone ranges and basins in the east, and ancient mountains and hills in the southeast. The central parts of Serbia are dominated by hills, low and medium-high mountains, interspersed with numerous rivers and creeks. The main communications and development line stretches southeast, with major cities located on or around. On the East, the terrain quickly rises to limestone ranges which are relatively sparsely populated. The height of mountains slowly rises towards southwest, but they do not form real ridges. The climate of Serbia is moderate continental, with the average annual air temperature for the area with the altitude of up to 300 m of 11°C and annual precipitation which ranges from 540 to 820 mm in lower regions, up to 700 to 1000 mm on altitudes over 1,000 m. Population/Demographics of Serbia After the II World War, only 26% of the Serbian population lived in urban areas. In the following 35 years, the percentage of people living in urban and non-urban population became equal, and in the last 30 years the number of people living in non-urban areas decreased rapidly. The results of the census held in Serbia in 2011 revealed that more than 40% of the Serbian population lives outside of urban areas, which is more than 2.9 million people. Another characteristic of this population is somewhat higher mean age of 43.6 years, compared to 41.3 years in urban areas. Considering that more than 20% of the Serbian working population is employed in agriculture, fishery and forestry, and that almost 2 million workers live in rural areas, we can assume that there could be more than a million-people active in the agricultural sector. All the above-mentioned facts underline the need for understanding the problems and needs of the aging rural population in Serbia, and developing a strategy to answer those needs.
Urban Non-urban
80% 74% 72% 70% 66%
58% 59% 60% 56% 53% 54% 50% 47% 46% 44% 42% 41% 40% 34% 28% 30% 26%
20%
10%
0% 1948 1953 1961 1971 1981 1991 2002 2011
Figure 1. Fraction of Serbian population living in urban and non-urban areas in the last 60 years.
74 According to the most recent census results, Serbia has a population of 7 million people, with a life expectancy of 72.6 years for men and 77.7 years for women. Each year the population of Serbia decreases by around 30,000 people, as the natural change per 1,000 people is -5.1 (minus 5.1). Another great problem of Serbia is its ageing population, as Serbia is considered a demographically old nation, with 17.4% of its residents being aged 65 years and older in 2011. There are more people over the age of 64 who need to be provided for than young people under the age of 15. It is clear that Serbia is facing a negative demographic pattern, characterized by depopulation, fertility decline and demographic aging. While the total population has decreased, the proportion of elderly continues to increase, and according to the European Yearbook for 2006, Serbia belongs to the 25 oldest nations. Serbian census data from 2011 indicates that there are: 949 villages with population <100 and >50, 531 with less than 50 inhabitants and 8 villages with only 1 inhabitant and five of them are older than 80 years. Average age of population living in those small villages is 57 years for villages with population <100 and >50 and 60 years for villages with less than 50 inhabitants. Main Health Problems of Serbian Population During the 90s, the population of Serbia experiences several social and economic threats, and years under severe stress and trauma-ridden environment have brought depression and hopelessness, followed by a general negligence towards health and increased risky behavior. Ischemic heart disease, cerebrovascular diseases, lung cancer, unipolar major depression, and diabetes mellitus were responsible for 70% of the total burden of health disorders in 2002. The burden of reported conditions was higher for males. The five main causes for disability-adjusted life years (DALYs) were ischemic heart disease, stroke, lung cancer, road traffic injuries, and self-inflicted injuries. For females, they were stroke, ischemic heart disease, depression, breast cancer, and diabetes mellitus.
Aim (Problems and Solutions) The aim of this presentation was to identify the most important problems of the Serbian aging rural population and discuss the potential solutions.
Identified problems Primary health care The Ministry of Health of the Republic of Serbia and the Institute for Public Health “Dr Milan Jovanović-Batut” have conducted a research on the health of the Serbian population, including the rural population in 2006, and published the results in 2013 (REF). The results have shown that the closest doctor’s office (examination room) for more than 23% of people living in rural areas is 4 km away. More than 60% of the Serbian rural population lives more than 4 km away from the closest Primary Health Care facility, and almost 50% of the Serbian rural population lives more than 4 km away from the closest pharmacy. Additionally, 89% of the rural population lives more than 4 km away from the closest hospital, and almost 7% of the rural population needs more than 1 hour to arrive to the closest hospital. Coupled with the fact that the rural population of Serbia sees their health as very bad and bad in more than 50% more cases than the urban population, the need for the availability of primary health care services is underlined even more. The survey has revealed also that almost 50% of the rural population has hypertension, with higher values of systolic and diastolic blood pressure than urban population, coupled with more than 70% not using their prescribed therapy regularly. There are important differences between various regions of Serbia which should be considered. In the mountain areas there is a smaller prevalence of cardiovascular diseases than in the plains and lower regions. An explanation can be sought in lower caloric intake and higher physical activity in mountainous areas, and meals richer in saturated fats in the plains, most typically represented by Vojvodina (northern part of Serbia where the elderly suffer from stroke and ischemic heart disease more often). Oral care Unfortunately, there is a common misconception among the general population of Serbia, including the rural population, that oral health is somehow separated and less important than general health. Modern approach to oral health underlines that it is an inseparable part of general health, it represents more than just healthy teeth, and a person cannot be considered healthy without oral health.
75 Apart from rural population unperceived needs for dental care services there are barriers preventing the rural population from accessing adequate dentist care which are represented by the low availability of dentist services in rural areas, limited financial means available for dental care and the problems of transport to nearest service. The rural population therefore has a higher prevalence of oral caries and periodontological diseases, lower coverage with quality fluoridated water, lower number of dentists per capita, and much higher distance to the first available dentist. It has to be kept in mind that aging rural population can be considered the population of special interest of dentists, since the number of studies have shown a higher oral diseases rate among persons older than 65 in rural, compared to urban populations. In Serbia, the data indicate a very bad situation regarding oral health in the rural population. The main identified predictors of unsatisfactory oral health are the low participation of the local community, low income, higher rate of caries, and lack of dentists. A pilot study in Serbia has shown that the rural population makes fewer visits to the dentist office than the urban population, 24.4% of rural population has own dentist versus 42.7% of urban population. Only 23.5% of rural inhabitants visited dentist in last 12 months versus 36.1% in urban population. The most surprising fact is that 2.8% of rural population never visited dentist. Gynecological care Gynecological care for rural population suffers from almost the same problems as oral care. There is a problem of perceived needs among rural women for preventive gynecological exam, low availability of gynecologists in rural areas and consequently problem of appointments as well as problems of transport to a nearest service. Gynecologists in rural areas claim that they do not have modern equipment nor consumables. As result almost 8% of rural women never visited gynecologist, and only 29% of them visited gynecologist in last year. Specialized care for the elderly Regardless of the figures showing the aging of the Serbian population, only a few health care institutions are specialized in care for elderly patients. An additional disadvantage for the rural aging population is that most of these institutions are located in Belgrade, the capital of Serbia. Even in Belgrade these institutions are represented only by the Geriatric University Clinic and several geriatric wards in major hospitals. In Belgrade is located also the only institute providing home treatment and community care for the elderly. Another chronic problem of the aging population is the rise in hospitalization rates. While patients aged 70 years and older made up 17.1% of all hospital admissions in 1997, this proportion reached 22.7% in 2007. The problem becomes even bigger when the total number of hospital beds is decreasing. Influences of working and living conditions on health of rural population Work and life in rural areas of Serbia are connected with exposures to a number of hazards for human health. The data on sanitary surveillance from two Serbian rural districts indicates that only 2.6% of small scale water supply systems were managed by public utilities, while 97.4% of them were operated by, group of citizens, and various committees that are not recognized as legal entities for service provision. The most common type of water sources in mountainous areas was protected spring 98.9%. The main public health concern is the fact that the water from 93.2% small scale water supply systems in mountainous areas is not being disinfected. Water supply problem is strongly linked with issues of wastewater and sewage systems which are in rural areas rarely available. It should be mentioned that in Serbian rural areas there is no sewage treatment plant. Life in rural areas is usually connected with work in agriculture which is source of a number of human health hazards. The most important ones are exposures to: pesticides, heavy physical workload, unphysiologically postures, noise, vibration, UV radiation, injuries, bacteria, viruses, poor sanitary conditions, high and low temperatures. It should be also mentioned that work life Serbian in rural areas starts very early with 12-15 years and that, in most cases, it never ends. All mentioned factors significantly influence health of rural population.
Solutions and Conclusions General measures Providing adequate health care to Serbian rural population is challenging task. But there are examples of good practice indicating that it is not impossible mission. One of the problems is that Serbian
76 population expects that state will solve their problems and they are patiently waiting for it. In areas were local communities decided to address the health needs of rural population we had serious breakthrough. Even a small-scale initiative gave important results. It could be a simple visit of local hospital doctors to a nearby villages up to fully developed screening programs for rural population. Investment in local infrastructure might be to expansive for local communities but in that case they should consider investment in all-terrain vehicles which might transport a patient to a nearest health care institution. It is the same with small scale water supply systems, local communities should at least invest in proper chlorination of water and in water quality control to prevent waterborne diseases. One of the important tasks for local rural communities is to promote health and health life styles through organizing discussions, public hearings and campaigns in collaboration with local health care institutions. This will also help health care institutions to better understand local needs and consequently to better address their needs. Primary health care Serbian primary health care institutions should invest more effort to meet needs of rural population. Since, whole primary health care system is state owned, and it is based on solidarity, responsible managers should pay more attention to rural areas. The first step in remote areas might be a first education of 5-10% of village population as well as provision of all necessary equipment for first aid in those villages. They should also organize nurse home visits and develop call centers in which doctors should provide basic medical advices. Among the first steps, which are easy to install, providing medication for more than a month is one of the most important for quality of life improvement (according to actual Serbian legislation prescription of medication for only one month is allowed). Education on health and safety in agriculture is also important issue for improvement of rural health. Basic information’s on health and safety in agriculture should be provided by primary health care units using field nurses as an important education channel. After improvement of basic rural health services and with social and technological development primary health managers should start with telemedicine and health services. Oral health The bad condition of oral health in the Serbian rural population is a product of geographical isolation, low access to quality transportation (from their homes to the dental offices), lack of fluoridation of water, poverty, lack of dental professionals in rural areas, and the higher percentage of older people in the rural population. Nevertheless, the aging rural population deserves and has the right to quality oral health care, which is why it is necessary to develop recommendations which can increase their access to it. General approach to achieve this goal represents the continuous education of dentists to answer the need of the aging rural population, organization of Health Prevention Weeks where the rural population could get easy and free access to diagnostic procedures and learn how to better take care of their oral health. On of solutions is to involve dentistry students and teachers in preventive programs for rural population. Faculties might organize mobile dentistry units and through win-win situation provide education for their students during summer practice and free access to oral care to inhabitants of rural areas. Another important decision is the development of rural dental care offices which would allow the rural population access to oral health care at their place of living, as well as interventions such as local fluoridation of water. More specific goals are represented by the reduction of orthodontal anomalies and elimination of factors which facilitate the development of parodontopathy, reduction of teeth extraction in cases where the tooth could have been treated conservatively, and increase the percentage of adults (especially in the aging rural population) which have regular dental exams. Specialized health care for the elderly Contrary to popular belief in Serbia, treatment for the elderly should not be a privilege. Making mandatory the allocation of a certain number of beds (0.2 per 1,000) for “prolonged care” (up to 30 days) was a positive step forward. Most often, these capacities are used by geriatric patients, but also for palliative care, chemotherapy patients, and those requiring physical rehabilitation treatments. It is important to note that for elderly patients, more often it is care than treatment what is needed. There is a particular gap identified in the education of health professionals. Although modern geriatrics in the region have been in development since 1963, this branch of medicine has been
77 underrepresented, especially considering the needs of our country, until today. A survey has revealed that only 3 out of 4,770 lessons of the curricula for qualified nurses are dedicated to elderly patients and their problems.
Conclusion First steps in improving health of Serbian rural population are not financially demanding but for further steps there is need for significant investment as well as much more better coordination among stakeholders.
Profile: Born on August 9, 1961 in Belgrade. The Medical Faculty in Belgrade finished in January 1986 with an average grade of 9.28. He defended his master's thesis in 1991 at the Center for Multidisciplinary Studies at the University of Belgrade. His doctoral dissertation he defended at the Medical Faculty in Belgrade in 1994. In 1992, he earned degree of Occupational health specialist at the Medical Faculty in Belgrade and eight years later he earned superspecialist degree in Occupational toxicology also at the Faculty of Medicine in Belgrade. In addition to his professional development in the country, he attended several courses abroad (Turin, Pavia, Wageningen, Dresden, Amsterdam) and had post-doctoral studies in Ghent (Belgium). His teaching career started in 1989 at University of Belgrade Faculty of medicine as assistant trainee within Occupational health chair. He became assistant in 1992 and an assistant professor in 1995. Associate professor in Occupational health he becomes in 2000, since March 2009 he is a full professor. Since October 2012 he has been working as a vice-dean for clinical teaching at the Medical Faculty in Belgrade. In parallel with his university career, he started his professional career, starting with as a clinical doctor at the Institute of Occupational Medicine in 1989, through a occupational health specialist doctor in 1992, head of the Department of Professional Toxicology from 1995 to 2009, to the Assistant Director of the Institute of Occupational Health from 2001 to 2009. From May 2011 to October 2012, he served as Assistant Minister of Health responsible for International Cooperation and European Integration. He is a member of the National Council for Safety and Health at Work, as well as the Board of the International Association of Rural Health and Medicine. Since 2001 he is a member of the Collegium Ramazzini. He is active in a number of international organizations. In the period 2006-2015, he was Vice President of the European Association of Schools of Occupational Medicine. He is World Health Organization focal point for Occupational health.
78 79 IARM 基調講演 ⑥（第 2 日目）10 a.m.
高齢化するセルビアの地方住民： 必要とされる医療とその解決法の検討 Prof. Petar Bulat（セルビア） University of Belgrade Faculty of Medicine & Serbian Institute of Occupational Health, Belgrade, Serbia
緒言／背景 セルビアの基本情報 セルビアは東南ヨーロッパのバルカン半島に位置する比較的小さな国である。面積は88,361 km2（34,116平 方マイル）で、そのうち19,194 km2（24.8%）は耕地、19,499 km2（25.2%）は森林が占めている。地形は、北 部の豊かで肥沃な平原地帯（Vojvodinaヴォイヴォディナ）、東部の石灰岩の山地や盆地、南東部の太古以来の山 岳・丘陵地帯と変化に富んでいる。セルビア中央部は丘陵や低・中程度の高さの山々が多く、その間を無数の川 や小川が流れている。通信開発の主要ラインは南東方向に伸び、そのライン上および周辺に主要都市が位置して いる。東部に向かうと地形は急峻な石灰岩の山地となり、人口は比較的少ない。南西部に向かって山々の高度は 徐々に高くなるが、山脈を形成してはいない。 セルビアの気候は穏やかな大陸性気候で、海抜300 mまでの地域の年間平均気温は11°C、年間降水量は低地で 540–820 mm、海抜1,000 m以上の高地では700–1000 mmである。 セルビアの人口統計 第二次世界大戦後、都市部に住んでいたのはセルビアの人口の26%に過ぎなかった。続く35年間に都市部と非 都市部の人口の割合は等しくなり、ここ30年間で非都市部に住む人の数は急速に減少した。2011年のセルビア 国勢調査によると、セルビア人口の40%以上、すなわち290万人以上が都市部以外に住んでいることがわかった。 別の特徴として、都市部以外に住む人口の平均年齢は43.6歳で、都市部に住む人口の平均年齢41.3歳よりやや高 い。セルビアの労働人口の20%以上が農業、漁業、林業に従事していること、および約200万人の労働者が地方 に住んでいることを考えると、農業セクターでは100万人以上が現役で働いていると推測できる。上記の事実か ら、高齢化するセルビアの地方住民が抱える問題や必要なことを理解し、それに対応する戦を作り上げる必要性 が明確になる。＜図1＞ 直近の国勢調査によると、セルビアの人口は700万人、平均余命は男性72.6歳、女性77.7歳である。セルビア の人口は毎年約3万人ずつ減少しており、人口の自然変化は1,000人当たり−5.1となっている。別の大きな問題と して人口高齢化がある。セルビアは高齢国とみなされており、2011年には人口の17.4%が65歳以上であった。扶 養してもらう必要のある64歳以上の人の数は、15歳以下の若年層の数より多い。明らかにセルビアは、人口減 少、出生率低下、人口高齢化を特徴とする負の人口構造パターンに直面している。総人口が減少している一方で
Urban Non-urban
80% 74% 72% 70% 66%
58% 59% 60% 56% 53% 54% 50% 47% 46% 44% 42% 41% 40% 34% 28% 30% 26%
20%
10%
0% 1948 1953 1961 1971 1981 1991 2002 2011
図1. 過去60年間のセルビア人の都市部と非都市部の人口割合
80 高齢者の割合は増加を続けており、ヨーロッパ年鑑2006（European Yearbook for 2006）によると、セルビア は最高齢国25か国の1つである。 2011年セルビア国勢調査のデータによると、人口が50人より多く100人未満の村は949、50人以下の村は531、 1人だけの村は8つあり、1人だけの村の住民のうち5人は80歳以上である。これら小さな村の住民の平均年齢は、 人口が50人より多く100人未満の村では57歳、50人以下の村では60歳である。 セルビア国民が抱える主な健康問題 90年代にセルビアの人々はいくつかの社会的および経済的脅威を経験した。深刻なストレスやトラウマになり やすい環境のもとでの年月はうつ病や絶望感を引き起こし、それが健康に対する全般的な無関心や危険行為の増 加にもつながった。2002年には、虚血性心疾患、脳血管疾患、肺がん、単極性大うつ病、および糖尿病が、健 康障害の総負荷のうち70% の原因となっていた。疾患負荷は男性のほうが高かった。障害調整生存年数 （disability-adjusted life years：DALYs）の5大要因は、男性の場合は、虚血性心疾患、脳卒中、肺がん、交通 外傷、自傷行為によるけが、女性の場合は、脳卒中、虚血性心疾患、うつ病、乳がん、糖尿病だった。
目的（問題と解決方法） 本稿の目的は、高齢化するセルビアの地方社会における最重要課題を特定し、可能性のある解決策を検討する ことである。
特定された課題 一次医療 セルビア共和国の保健省および公衆衛生研究所「ドクター・ミラン・ジョバノビッチ・バトゥ（Dr. Milan Jovanović-Batut）」は、2006年に地方住民を含むセルビア国民の健康に関する研究を行い、2013年に結果を発 表した（REF）。その結果、地方住民の23%以上は、最寄りの診療所（診察室）から4 km離れた場所に居住して いることがわかった。また、セルビアの地方住民の60%以上は、最寄りの一次医療施設から4 km以上離れた場 所に住んでおり、約50%は最寄りの薬局から4 km以上離れた場所に住んでいる。 さらに、地方住民の89%は最寄りの病院から4 km以上離れた場所に住んでおり、約7%は最寄りの病院まで1 時間以上かかる場所に住んでいる。セルビアの地方住民で自分の健康状態が非常に悪いあるいは悪いと考える人 の割合は、都市住民の場合と比較して50%以上高いという事実を合わせると、一次医療サービスを利用できるよ うにする必要性がいっそう明確になる。 調査では、地方住民の約50%が高血圧であり、収縮期および拡張期血圧が都市住民より高いこともわかった。 さらに、70%以上の人は処方された治療を定期的に受けていない。 セルビアの各地域間には際立った差異があり、それらを考慮に入れる必要がある。山岳地帯における心血管疾 患の有病率は平原および低地よりも低い。その理由として、山岳地帯ではカロリー摂取量が少なく身体活動量が 多く、ヴォイヴォディナ（脳卒中や虚血性心疾患の高齢者がより多いセルビア北部の地域）に代表される平原地 帯の料理には飽和脂肪が多く含まれることが挙げられる。 口腔ケア 残念なことに、地方住民を含むセルビアの一般国民の間では、口腔衛生は全身の健康とは別であり、それほど 大切ではないという誤解がよく見られる。現代では、口腔衛生が全身の健康と切り離せないこと、口腔衛生には 単なる歯の健康以上の意味があり、それなくして健康はあり得ないことが強調されている。 歯科治療の必要性に対する地方住民の認識の低さはさておき、地方住民が適切な歯科治療を受ける妨げになる のは、地方では歯科治療サービスが少ない、歯科治療を受けるための経済力が限られている、最寄りの歯科まで の交通手段がない、といった問題である。地方住民の虫歯および歯周病の有病率は高く、高品質なフッ素添加水 が供給される範囲は限られており、1人当たりの歯科医の数は少なく、最寄りの歯科医院からの距離は遠い。 数多くの研究が示すとおり、65歳以上の地方住民の口腔疾患罹患率は都市住民の場合より高いため、高齢化す る地方住民は歯科医にとって特別な関心を払うべき対象であることに留意したい。データからは、セルビアの地 方住民の口腔衛生状態が非常に悪いことがわかる。口腔衛生不良の主な予測因子として同定されているのは、地 域コミュニティとの関わりの少なさ、低収入、高い虫歯率、歯科医の不足である。セルビアで行われたパイロッ ト研究によると、地方住民は都市住民よりも歯科医院に行く回数が少なく、かかりつけの歯科医院がある人の割 合は地方住民で24.4%なのに対し都市住民では42.7%である。過去12ヶ月間に歯科医院に行った人の割合は、地 方住民ではわずか23.5%、都市住民では36.1%である。最も驚くべき事実として、地方住民の2.8%は一度も歯科 医院に行ったことがない。 婦人科医療 地方住民に対する婦人科医療は、口腔ケアとほぼ同様の問題を抱えている。予防的婦人科検診の必要性に対す る地方の女性の認識は低い。また、地方において婦人科医の数は少なく、結果として予約も取りにくいことに加 え、最寄りの医療施設までの交通手段の問題もある。地方の婦人科医は、現代的な設備や消耗品がないと訴えて
81 いる。その結果、地方の女性の約8%は一度も婦人科に行ったことがなく、前年に婦人科に行った女性はわずか 29%であった。 高齢者に対する専門医療 統計がセルビアの人口高齢化を示しているにもかかわらず、高齢患者の治療に特化した医療施設は数少ない。 高齢化する地方住民にとってさらに不利なことに、これらの医療施設のほとんどはセルビアの首都ベオグラード にある。ベオグラードにおいてさえ、老年学大学病院（Geriatric University Clinic）に加えて、いくつかの大 病院に高齢者病棟があるにすぎない。また、高齢者への在宅治療および地域ケアを提供する唯一の機関もベオグ ラードにある。人口高齢化に伴う別の慢性的問題として入院率の増加が挙げられる。1997年には全入院患者の うち70歳以上の患者が占める割合は17.1%だったのに対し、2007年にはその割合が22.7%に達した。総病床数が 減少するにつれて、この問題はより顕著になっている。 地方住民の健康に対する労働環境及び生活環境の影響 セルビアの地方での労働や生活においては、健康に有害な要因にさらされることが多い。セルビアの2つの地 方を対象とした公衆衛生調査によると、小規模な水道システムのうち公益企業が管理しているのはわずか2.6% にすぎず、97.4%は市民団体や、サービスを提供する法人組織として認可されていない種々の委員会によって運 営されている。山岳地帯の水源のタイプで最も多いのは保護された湧水で98.9%を占めている。公衆衛生上の主 な懸念として、山岳地帯の小規模水道システムのうち93.2%から供給される水は消毒されていない。水供給の問 題は、排水・汚水処理システムの問題と強く結びついている。これらのシステムは地方にはほとんどない。セル ビアの地方には下水処理場が存在しないことに触れておく必要がある。 地方の生活は一般的に農作業と結びついているが、農作業は数多くの健康被害の原因となっている。最も重大 なのは、農薬、重い身体的作業負荷、非生理学的な姿勢、騒音、振動、紫外線、怪我、バクテリア、ウイルス、 不衛生な状態、高温や低温にさらされることである。セルビアの地方では、12–15歳という非常に若い時期に労 働生活が始まり、大抵の場合終わりはないという点にも触れておきたい。 上記すべての要因は地方住民の健康に重大な影響を与えている。
解決策および結論 一般的対策 セルビアの地方住民に適切な医療を提供するのは困難な課題である。しかし、不可能な任務ではないことを示 す良い実例もある。1つの問題は、セルビア国民は国が自分たちの問題を解決してくれるものと期待して辛抱強 く待っている、という点にある。地域コミュニティが住民の健康上の問題に対応する決断をした地域では大きな 進展が見られた。たとえ小さな取り組みであっても大きな成果が上がっている。地元の病院の医師が近くの村を 訪問するという簡単なものから、地方住民のための充実した健診プログラムまで、さまざまな取り組み方が考え られる。 地域インフラへの投資は、地域コミュニティにとって壮大すぎる話かもしれない。もしそうなら、患者を最寄 りの医療施設に運べる全地形対応車への投資を検討するとよい。小規模水道システムの場合も同様で、地域コ ミュニティは少なくとも水の適切な塩素処理および水質管理に投資して、水媒介の病気を防ぐ必要がある。 地方コミュニティが果たす重要な役割の1つは、地元の医療施設と協力して検討会、公聴会、キャンペーンな どを企画し、それらを通じて健康および健康的なライフスタイルを促進することである。この取り組みによって 医療施設も地元の必要に対する理解を深め、その必要によりよく対応できるようになる。 一次医療 セルビアの一次医療施設は、地方住民の必要を満たすことにより多くの労力を注ぐべきである。全体的な一次 医療制度が国によって運営されており、社会的連帯を基礎としているため、管理責任者が地方にもっと注意を向 ける必要がある。遠隔地域における第一段階の取り組みには、村民の5–10%に初歩的な教育を行うことに加え て、村で応急手当を行うのに必要な設備一式を提供することが含まれるだろう。また、看護師による往診を組織 したり、医師からの基本的な医療アドバイスが受けられるコールセンターを開設する必要もある。導入が簡単な 第一段階の取り組みのうち、生活の質を改善するのに最も重要な点の1つは、1ヶ月分以上の薬を提供することで ある（現行のセルビアの法律で処方が認められているのは、1ヶ月分までの薬である）。農業に関する安全衛生教 育も、地方住民の健康状態を改善するための重要課題である。農業における安全衛生の基礎知識は、一次医療を 行うチームが提供し、訪問看護師に指導員としての主な役割を担ってもらうとよい。 地方の一時医療サービスが向上し、社会的・技術的発展が見られたなら、衛生管理責任者はまず遠隔医療サー ビスに取り組む必要がある。 口腔衛生 セルビアの地方住民の口腔衛生状態が悪いのは、地理的な孤立、家から歯科医院までの質の高い交通手段の不 足、フッ素添加水の不足、貧困、地方における歯科医療従事者の不足、地方人口における高齢者の割合の高さな
82 どに起因している。このような状況ではあるが、高齢化する地方住民には質の高い口腔衛生ケアを受ける権利が あり、その機会を増やすための提言を作成する必要がある。この目標を達成するための一般的取り組みには、高 齢化する地方住民の必要に対応できるよう歯科医に対する継続的な教育を行うこと、健康管理週間を企画して、 地方住民が無料で診断を受け、口腔衛生にもっと注意を払う方法を学ぶ機会とすることなどがある。1つの解決 策は、歯科学生や教員に地方住民のための予防プログラムに参加してもらうことである。歯学部が移動歯科チー ムを組織し、夏の実習の一環として学生を指導すると同時に地方住民には無料の口腔ケアを提供するなら、両方 にとってメリットがある。 別の具体的なゴールとして、地方に歯科医院を開設し、地方住民が自分の住んでいる場所で口腔衛生ケアを受 けられるようにすること、および水にフッ素を添加するといった介入に関与する点がある。 より具体的な目標には、不正咬合を減らす、歯周病が起こりやすくなる要因を除去する、保存治療ができたは ずの抜歯を減らす、（特に高齢化する地方住民のうち）定期的に歯科検診を受ける人の割合を高める、などがある。 高齢者に対する専門医療 セルビアで一般的に考えられているのとは反対に、高齢者への治療が特権であってはならない。「長期介護」 （30日まで）用に一定数のベッド（1,000床当たり0.2床）の設置が義務付けられたのは積極的な一歩である。多 くの場合、これらのベッドは高齢患者のために使用されるが、緩和ケア、化学療法、身体リハビリテーション治 療を必要とする患者のために使用されることもある。高齢患者の場合、治療よりも介護が必要な場合が多いこと に注意しなければならない。 医療従事者への教育には大きな不足が見られる。現代の老年医学は1963年以降発展してきたが、医療におけ るこの分野は、特に我が国での必要性を考えると、現在まで過小評価されてきた。調査によると、有資格看護師 になるためのカリキュラムを構成する4,770の授業うち、高齢患者とその問題に特化した授業は3つしかないこと がわかっている。
結論 セルビアの地方住民の健康を改善する取り組みの第一段階は、経済的負担の大きいものではない。しかし、取 り組みをさらに進めるには、かなりの投資に加えて関係者間での一層の協調が必要となる。
略歴：1961年8月9日、ベオグラード（セルビア）生まれ。1986年、ベオグラード大学を卒業、1991年、学際的研究でベオグラード 大学で修士終了し、1994年に博士。1992年にOccupational health specialist、8年後にsuperspecialist degree in Occupational toxicologyとなる。その後、国外（Turin, Pavia, Wageningen, Dresden, Amsterdam）でも学び、ベルギーのヘント（Ghent）で ポスドクの業績をあげる。1989年、ベオグラード大学assistant trainee within Occupational health chair。1995年、assistant professor。2000年、Associate professor in Occupational health。2009年から主任教授。2011年5月～2012年10月まで、Health responsible for International Cooperation and European IntegrationのAssistant Ministerとして従事した。National Council for Safety and Health at Workと国際農村医学会International Association of Rural Health and Medicine（IARM）の理事であ る。2006年から2015年まで、産業医学校のヨーロッパ連合European Association of Schools of Occupational Medicineの副会 長であり、またWHOのOccupational health労働衛生部門の中心人物である。
83 IARM Keynote Lecture ⑦（Day 2）11 a.m.
Prevention of occupational risks and diseases in agriculture Dr. Shengli Niu（スイス） International Labour Organization（国際労働機関 ILO）
Keywords: occupational diseases, diagnostic criteria, exposure criteria, Agriculture
Introduction Agriculture is one of the most hazardous of all economic sectors and many agricultural workers suffer occupational accidents and ill health each year. It is also the largest sector for female employment in many countries, especially in Africa and Asia. Agriculture employs some one billion workers worldwide, or more than a third of the world's labour force, and accounts for approximately 70 per cent of child labour worldwide. Work in agriculture may involve exposures to chemicals (insecticides, herbicides, fungicides and fumigants), growth regulators (growth inhibitors and ripening agents), dangerous pests, insects, animals and their wastes, dangerous machineries and tools, manual handling of loads, awkward working positions, long working hours, harsh weather conditions, poor welfare and accommodation facilities. In developing countries, workers and farmers face greater risks due to the use of toxic chemicals – which are banned or restricted in other countries – incorrect application techniques, poorly maintained equipment, inadequate storage practices, and the reuse of old chemical containers for food and water storage. The end users often do not have access to information on the risks associated to the use of chemicals and on the necessary precautions and correct dosage. The total number of pesticide poisonings has been estimated between 2 and 5 million per year, of which 40,000 are fatal.
Methods: Description of the ILO activities on the protection of workers against exposure to risks at workplace in agriculture.
Results: The ILO uses various means of action to give governments and employers’ and workers’ organizations the necessary help in drawing up and implementing programs for the control of workplace risk factors in agriculture. These means include international standards in the form of legal instruments, codes of practice, practical manuals, training materials and education and training and technical cooperation. They include the Safety and Health in Agriculture Convention (No. 184) and Recommendation (No. 192), 2001, and the List of Occupational Diseases Recommendation, 2002 (No. 194). The ILO code of practice on Safety and Health in Agricultural Work (1965), the Code of Practice on Safety and Health in Agriculture (2010), the ILO Encyclopedia of Occupational Health and Safety, and manuals and training materials on Occupational safety and health in Agriculture. The ILO collects information on good workplace practice on occupational safety and health and on the identifications and recognition of diseases caused by occupational hazards in agriculture and provides support for the applications of the relevant ILO instruments in member States. The ILO develops guidance notes on the diagnostic and exposure criteria for occupational diseases caused by risk factors in agricultural work.
Profile: Dr. Shengli Niu was trained in medicine and specialized in occupational health. He is currently working as a senior specialist in occupational health at the Headquarters of the International Labour Office in Geneva, Switzerland. He has worked in the fields of occupational health, radiation protection of workers and ergonomics for about 30 years. He had worked for the Ministry of Health of the People’s Republic of China for eight years and for the World Health Organization for two years at its Beijing Office before he joined the ILO in 1994. He is responsible for activities in the field of occupational health and safety including occupational health services, health surveillance of workers, occupational safety and health in agriculture, identification and recognition of occupational diseases, ergonomics, and occupational radiation protection. Dr. Niu has led a number of international efforts in developing global policies and standards on occupational safety and health including the revision of the ILO’s international list of occupational diseases and the development of international practical guidelines on ergonomics at the workplace. He has been the ILO focal point on radiation protection since 1994. He also serves as a member or representative of the ILO at several international experts/standards committees relevant to safety, health and radiation protection.
84 IARM 基調講演 ⑦（第 2 日目）11 a.m.
農業における職業病のリスクと疾病の予防 Dr. Shengli Niu（スイス） International Labour Organization（国際労働機関 ILO）
Keywords: occupational diseases, diagnostic criteria, exposure criteria, Agriculture
緒言 農業は最も危険の多い経済セクターの1つであり、毎年大勢の農業従事者が労働災害や健康障害に苦しんでい る。農業は、特にアフリカやアジアの国々では、女性の雇用が最も多いセクターでもある。農業労働者は世界中 で約10億人、すなわち世界の労働人口の3分の1以上に上る。また、世界全体の児童労働者の約70%が農業に従 事している。農作業においては、化学物質（殺虫剤、除草剤、殺菌剤、燻蒸剤）や成長調整剤（成長抑制剤や熟 成剤）へのばく露、有害な生物、昆虫、動物、それらの排せつ物との接触、危険な機械や用具、人力での荷作 業、不自然な姿勢、長時間労働、厳しい天候、劣悪な福祉施設や宿泊施設などのリスクにさらされる場合があ る。発展途上国の労働者や農業従事者は、他の国では禁止または規制されている有毒化学物質の使用、誤った使 用法、器具の整備不良、不適切な保存方法、古い薬品容器の水・食品保存への再利用が原因で、より大きなリス クに直面している。エンドユーザーは、化学物質の使用に伴うリスク、必要な注意事項、適切な用量などの情報 にアクセスできないことが多い。農薬中毒の事例の総数は毎年200万～500万件と推定されており、そのうち4万 件は命に関わる事例である。
方法 農作業環境において直面するリスクから労働者を保護するためのILO（国際労働機関）の活動について述べる。
結果 ILOはさまざまな手段を通じて、政府機関、雇用者団体、労働者団体が農業作業環境における危険因子のコン トロールを目的としたプログラムを策定・実施するのに必要なサポートを提供している。これらの手段には、国 際基準を定めた法的文書、行動規範、実用的マニュアル、トレーニング資料、教育・トレーニング、技術協力な どがある。2001年に採択された「農業における安全及び健康に関する条約」（第184号）、同「勧告」（第192号）、 2002年に採択された「職業病一覧表に関する勧告」（第194号）、「農作業における安全及び健康に関するILO行 動規範」（1965年）「農業における安全及び健康に関するILO行動規範」（2010年）、「ILO労働安全衛生百科事 典」、農業における労働安全衛生に関するマニュアルやトレーニング資料などがこれに含まれる。ILOは、労働 安全衛生面での作業環境の規範や農作業中の危険に起因する疾病の識別・認識に関する情報を収集し、関連する ILO文書を適用できるように加盟国をサポートしている。さらに、農作業中の危険因子に起因する業務上の疾病 についての診断基準および暴露基準を作成している。
略歴：Dr. Shengli Niuは、労働衛生occupational healthの専門家である。現在、ジュネーブ（スイス）のILO（国際労働機関）の労 働衛生部門のHeadquarterとして働いている。労働衛生分野、労働者の放射線被爆の防御、人間工学部門ergonomicsで、30年来働い てきた。1994年以降、ILOの放射線被爆の防御部門の中心である。その他、ILOの安全、健康衛生、放射線被爆の防御に関する部門の 代表として活躍している。
85 IARM Keynote Lecture ⑧（Day 2）15 p.m.
Answers of the ISSA to challenges for social security in rural areas Dr. Joachim Breuer（ドイツ） President of the International Social Security Association (ISSA) German Social Accident Insurance (DGUV)
Though the globalisation in general brings the regions of the world closer together, rural areas are increasingly left behind. Three quarters of the world's poorest people live in rural areas in developing countries. Not only do they depend on small-scale agriculture for their livelihoods, they are at the same time confronted with numerous complex challenges on a day-to-day basis such as climate change, unstable financial markets and food insecurity. Very often, they can face these severe conditions only with very limited resources and at the same time are lacking social protection, which would serve as a safety net in times of need. The ISSA has identified 10 Global Challenges for Social Security for which we are providing answers in order to cope with the developments of our time. From a social security perspective, one of the main challenges in rural areas is the lack of legal coverage. There still exist countries in which legal coverage is low, in others, legal coverage is high but obstacles are exacerbating the access to these services. Due to the high amount of seasonal work, informal work and migrant work in rural areas, the registration to social protection schemes is scarce. The multitude of individual cases makes it hard to meet the demand of agricultural workers. Inadequate service provision and a mis-match of social security systems to the real needs of rural employed persons are a result of this. The fragmentary infrastructure in rural areas generates additional difficulties in securing sufficient and suitable services for health and long-term care. This situation is exacerbated by ageing rural communities in many industrialized countries. The answers to the indicated challenges in rural areas are manifold but need to be chosen wisely in order to avoid wasting resources or gambling with people's trust. The first very promising approach is the application of new technologies, e.g. apps but also the possibility of mobile payments that can help close the coverage gap and increase accessibility and adequacy of services. Also research triggering policy and administrative strategies will help to match the requirements of the rural people to the services provided. Specific approaches for rural workers are recognized as possessing high potential to face the challenges indicated. One such approach is the possibility for integrated methods for social security provision. Also relaxed administrative rules, e.g. allowing one contribution per year to health insurance in the harvest season rather than monthly payments can be part of such a specific approach. The most effective approach identified by the ISSA lies in strengthening the socio-economic role of social security in rural communities. A higher prevalence of non-contributory benefits for those without contributory coverage extents social protection. And the promotion of preventive measures reduces traditional risks. Linking social protection with rural productivity leads to sustainable growth by fighting poverty and enhancing income security, two very important conditions for also coping with serious occurrences as natural disasters or financial crises.
Profile: At present: President of the International Social Security Association (ISSA) Dr. Joachim Breuer studied law at the Universities of Bonn and Berlin, Germany. He obtained his degree in 1984 and became a doctor of law in 1985. After working for the German Federal Ministry of Agriculture and Forestry for five years, he joined the Federation of German Accident Insurance Institutions (HVBG) in St. Augustin, Germany. In 1995, he became Director General of the accident insurance and prevention institution for the German mining industry. In 2002, Dr. Breuer returned to HVBG (now DGUV)*, the umbrella organization of all German accident insurance funds in the industrial sector, this time as Director General. His international affiliations, most notably, are • President of the International Social Security Association (ISSA), Switzerland • Co-chair of the International Disability Management Standards Council (IDMSC), Canada • Member of the Bureau of the European Forum for Accident Insurances (FORUM) • Board member of the Pacific Coast University (PCU), Canada
86 IARM 基調講演 ⑧（第 2 日目）15 p.m.
農村地域における社会保障の課題に対するISSAの対応策 Dr. Joachim Breuer（ドイツ） President of the International Social Security Association (ISSA) （国際社会保証協会） German Social Accident Insurance (DGUV)
グローバル化によって一般的には世界の各地域間の関係が密接になったものの、農村地域はますます取り残さ れている。世界の最貧困層の4分の3は発展途上国の農村地域に住んでいる。そこに住む人々は、生計を小規模な 農業に頼っているだけでなく、気候変動、金融市場の不安定性、食糧不足など数多くの複雑な問題に日々直面し ている。多くの場合、これらの過酷な状況に限られた資源で立ち向かわなければならず、必要な時にセーフ ティー・ネットとなるはずの社会的保護もない。国際社会保障協会（ISSA）は「社会保障に関する10のグロー バル課題（10 Global Challenges for Social Security）」を明らかにし、現代の情勢に対処するための対応策を 提案している。 社会保障の観点からすると、農村地域の主な課題の1つは法的な保障が不足していることである。いまだに法 的保障制度への加入率が低い国もあれば、法的保障制度への加入率は高いものの、サービスへのアクセスを阻む 障害が存在する国もある。農村地域では季節労働、登録されていない労働（インフォーマル労働）、出稼ぎ労働 が多いため、社会的保護計画への参加は十分ではない。個別のケースが無数にあるため、農業労働者の需要を満 たすのは困難である。その結果、サービス供給の不足や、社会保障制度と農村労働者の本当のニーズとのミス マッチが生じている。農村地域のインフラが断片的であることも、十分かつ適切な医療・介護サービスの確保を 難しくしている。多くの工業国では、農村社会が高齢化するにつれてこの状況が悪化している。 農村地域における上述の課題への対応策は多種多様であるが、資源の浪費や人々からの信頼の喪失を避けるた めには賢く選ぶ必要がある。まず非常に有望な取り組みとして、アプリなど新しい技術の活用がある。またモバ イル決済も、保障制度の不足を埋め、サービスへのアクセスのしやすさやサービスの妥当性を高めるのに役立つ 可能性がある。さらに、研究に基づく政策や運営戦略は、農村地域に住む人々の必要に合わせたサービスを供給 するのに役立つであろう。農村労働者に特化した取り組みは、上述の課題への対応策として大きな可能性を持つ ことが認められている。1つの取り組みとして、社会保障給付の方法を統合する可能性が考えられる。また、運 営規則を緩和して、たとえば年間の健康保険料を毎月ではなく収穫期の年1回支払うことを認めるのも、このよ うな具体的取り組みの一つである。ISSAが最も効果的と認めている取り組みは、農村社会における社会保障の 社会経済的役割を強化する点にある。拠出制の保障（contributory coverage）がない人に対する無拠出制給付 の普及率が高いと、社会的保護は拡大する。予防的対策を推進することで従来のリスクも軽減される。社会的保 護を農村地域の生産性と関連づけるなら、貧困撲滅および所得保障の強化による持続可能な成長につながる。貧 困撲滅と所得保障の強化の2つは、自然災害や財政危機などの重大な出来事に対処するうえでも非常に重要な条 件である。
略歴：Dr. Joachim Breuerは、ドイツのボン大学ベルリン大学で法律を学んだ。1984年に学位を取得、1985年に法学博士。ドイツ Federal Ministry of Agriculture and Forestry で5 年間勤務し、その後、St. Augustin のドイツAccident Insurance Institutions （HVBG）に入る。1995年、Accident insurance and prevention institution for the German mining industry（ドイツ鉱業災害保 険予防協会）の会長となる。2002年、HVBG（現在のDGUV）に戻り、ドイツの事故災害保険ファンドを傘下に収め組織化した。彼は 国際的にも活躍しており、①ISSA（国際社会保障協会、スイス）の会長、②International Disability Management Standards Council （IDMSC）国際ディスアビリティ・ マネジメント標準協議会（カナダ）の共同議長、③ヨーロッパ事故災害保険フォーラム（FORUM） の会員、④太平洋岸大学Pacific Coast University（PCU）カナダの理事である。
87 IARM Keynote Lecture ⑨（Day 2）16 p.m.
The ageing population in Hungary ‒ facts, challenges and endowers in the health and social policy Prof. Dr. Istvan Szilard（ハンガリー） Department of Operational Medicine, University of Pécs Medical School, Hungary
General overview Hungary has an ageing and decreasing population of nearly 10 million inhabitants. The fertility rate is below of that of the European Union (EU): 1.4. Hungary is a high income country, according to the World Bank categorization, located in Central- Eastern Europe. The country is divided into municipalities: 328 cities – and 3 126 smaller settlements in rural area.
Characteristics of the ageing Hungarian population Life expectancy at birth in Hungary increased by nearly four years between 2000 and 2015, to 75.7 years, but remains still almost five years below the EU average of 80.6 years. A substantial gender gap remains as well: the life expectancy at birth of Hungarian men is almost seven years shorter than that of women (72.3 years compared to 79.0 years). Considerable differences in life expectancy could be observed between different socioeconomic groups. Life expectancy of those who have not completed their secondary education is more than 10 years shorter than that of those who have completed tertiary (university) level of education. Regarding healthy years of Hungarian women: the 60.1(HU) years is among the lowest third of the EU countries (63.1) while a difference is similar for men: 58.2 (HU) versus 62.6 (EU). There is also a considerable difference in life expectancy at birth between the majority population and ethnic minorities in Hungary. It is nearly ten years shorter among Roma people then the Hungarian average, while the German (Donau-Schwaben) minority’s health characteristics are better than the average.
Territorial and social inequalities As mentioned earlier, education level is one of the most determining factor for mortality and health status of people, but other characteristics of the socioeconomic status (income, occupational position etc.) are playing also a significant role. 65 < population from this point of view exposed to both: the ratio of those on pension is sharply increasing with the age – resulting lost in income and occupational position, inducing the feeling of social deprivation. The leading morbidity and death causes of the Hungarian population are more frequent among them: cardiovascular problems, cancer, musculoskeletal disease and mental health problems. Territorial differences in life expectancy within the country are also significant: there is a well detectable difference between the Eastern and Western territory of Hungary. Those, living alongside the western border, are showing significantly better life expectancy at birth figures. Even within the Capital, compering the data of the city districts, huge differences could be detected. These differences are highly correlating with socio-economic differences as well, but not really to age groups composition. These differences are present in the possibility to accessing the health care services, too. It could be detected well on the field of primary health care services, where the number of physicians countrywide is under the needed level. Unfortunately, in these handicapped regions there are several villages where locally no health consulting service is available.
Health insurance and social care system in Hungary with a focus on elderly population Hungary has a single-payer system, where the central government is playing a dominant role. The central government has almost exclusive power to formulate strategic direction and to issue and enforce regulations. Regarding Health Insurance, it is the Health Insurance Fund (HIF), administered by the
88 National Health Insurance Fund Administration (NHIFA) and is the most important national pool of financing in health care. Currently – as a result of reorganization – it has been incorporated into the State’s general budget, supervised directly by the government. Practically the entire Hungarian population (95%) is covered by the HIF. The health system’s major agencies and services have undergone an almost continuous process of (re)centralisation since 2012. Regarding long-term care services, personal social care (social services) is provided by the State and local governments on the basis of the Social Act (Act III of 1993). Local governments are obliged to organise the services, whereas NGOs and Churches may opt to participate. There is a well organized elderly care for Jewish holocaust survivors, operated by international and local funds. The Hungarian pension system provides a minimum pension with a qualifying condition of 20 years of service period, which amounts to HUF 28,500 (€108) per month in 2013. If the average contribution base is less than the amount of the minimum pension, the pension will equal 100% of the average monthly wage. Anyway, this figure is far below the average of the EU countries.
Health promotion programs for elderly people In accordance with the EU and WHO priority programs up to 2020: ‘Tackling inequality’ and ‘Healthy Ageing’ the Hungarian Parliament has adopted The National Strategy concerning Senior Citizens in 2009. Unfortunately, until now – in spite of some initiatives – no real successful project could be launched and evaluated.
Social care in rural area in Hungary As mentioned previously, in the health status and access to proper health care and social assistance, rural people, especially those who are living in small, remote settlements are suffering with handicap in comparison with the citizens living in cities. Mostly local self-governing bodies are setting up services like ‘day-care home’, social assistance nursing service etc.
Summary and highlights • In spite of the practically full coverage of health and pension insurance system for elderly people in Hungary, there are significant differences in their health status and access to health and social care services in general. • Although Hungary is an EU Member State and belongs to the category ‘high income country’, several inequities could be detected either intercountry or in-country relation. • On the field of social care for elderly people, the role of NGOs, churches and other charity organizations is very important.
■ REFERENCES / SOURCES OECD/ European Observatory: State of Health in the EU: Hungary; Country Health Profile 2017 Health inequalities and the social determinants of health in Hungary (Az egészség-egyenlőtlenségek és az egészsség társadalmi meghatározói Magyarországon) Summary report of the Health Inequalities and the Social Determinants of Health in Hungary working group, Editors: Éva Orosz and Zsófia Kollányi, Budapest, 2014 J. Sixsmith et al.: Healthy ageing and home: The perspectives of very old people in five European countries, ELSEVIER, Social Science & Medicine 106 (2014) 1-9 Johan P. Mackenbach et al.: Determinants of the magnitude of socioeconomic inequalities in mortality: A study of 17 European countries, ELSEVIER, Health & Place 47 (2017) Marzena Tambor and al.: Health Promotion for Older People in Hungary: The need for more action, Zdrowie Publiczne i Zarządzanie 2017; 15 (1): 96-107 Human rights of older persons in Hungary, Information for the Office of the United Nations High Commissioner for Human Rights on the promotion and protection of the human rights of older persons: https://www.google.pl/ url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwj35d_BufLRAhVrIJoKHQU4A lwQFggcMAA&url=http%3A%2F%2Fwww.ohchr.org%2FDocuments%2FIssues%2FOlderPersons%2FPublicCon sultation2013%2FHungary.doc&usg=AFQjCNFB0E3tfQ6VZYCu_i4Y0veFCXRQFw&sig2=jh6MzPG7KERoGBV -gpFk4g, accessed: 05.03.2018.
89 Profile: Education: MD and specialized in Internal Medicine and Public Health Medicine, Ph.D in Health Sciences. 2007: Professor tit. at University of Pécs. Professional career: 1992-1996 Associated Professor at the University of Pécs/ Hungary and the Postgraduate Medical University of Budapest. He joined IAAMRH in 1986, during professor Tényi’s presidency. He joined International Organization for Migration (IOM) in 1996 for planning and coordinating emergency and post-conflict humanitarian operations in the Balkans. He has been elected for Secretary General by the Executive Board and General Assembly of IAAMRH in Ayudhaya, Thailand, 23 July 2003, 2004- 2007 IOM Senior Migration Health Adviser for Europe and liaison person to EC/EU on migration health, posted in IOM European HQ, Brussels. In September 2007, he returned to University of Pécs/ Hungary and as Professor titular and Senior Scientific Adviser. He is acting as key coordinator for the migration and ethnic minority health projects and training programs. In 2014 in cooperation with WHO organized the international symposium on ‘Healthy ageing of Roma Communities’ that was concluded into a statement adopted by the WHO Regional Office. Since 2016 he is member of the core expert group responsible for the implementation of the WHO Migration Health Strategy and Action Plan in Europe. In March 2017, he was the coordinator and host of the European Network of Intercultural Elderly Care (ENIEC) conference in Pécs / Hungary. In 2017 the European Parliament awarded him with the ‘European Citizen’s Prize’. See more under:http://mighealth-unipecs.com/. He has published a total of 118 scientific articles, essays and book chapters
90 91 IARM 基調講演 ⑨（第 2 日目）16 p.m.
ハンガリーの高齢化 －その実態と健康・社会政策における課題や努力（endowers） Prof. Dr. Istvan Szilard（ハンガリー） Department of Operational Medicine, University of Pécs Medical School, Hungary
概要 ハンガリーの人口はおよそ1,000万人で、高齢化するとともに減少傾向にある。出生率は欧州連合（EU）の出 生率を下回る1.4である。中東欧に位置するハンガリーは、世界銀行の分類によると高所得国である。国内は市 町村に分割されており、328の市と地方にある3,126の小集落からなっている。
ハンガリーの高齢化の特徴 ハンガリーの出生時平均余命は2000年から2015年の間に4年近く延び、75.7歳に達したが、それでもEUの平 均である80.6歳よりは5年ほど短い。性別による差もいまだに大きく、ハンガリー人男性の出生時平均余命は女 性と比較すると7年ほど短い（男性72.3歳、女性79.0歳）。社会経済的グループ間でも平均余命の差がかなりある と考えられる。中等教育を終えていない人の平均余命は、高等教育（大学レベル）を修了した人と比較して10年 以上短い。ハンガリー人女性の健康寿命は60.1歳で、EU諸国（63.1歳）の中では下から3番目である。男性の場 合にも同様の差が見られ、ハンガリー人男性の58.2歳に対しEU諸国では62.6歳である。ハンガリーの多数派人 口と少数民族の間でも出生時平均余命に大きな差がある。ロマの人々の出生時平均余命はハンガリー人の平均と 比較して10年近く短い。一方でドイツ系少数民族（ドナウ・シュヴァーベン）の健康特性は平均よりも良い。
地域的・社会的格差 上述のように、教育レベルは人々の死亡率や健康状態に最も重大な影響を与える決定因子の1つであるが、社 会経済的地位に関連する他の特性（収入、職業的地位など）も大きな影響を及ぼす。この観点からすると、65歳 以上の人々はその両方の影響を受けやすいと言える。年金で暮らす人の割合は年齢とともに急増し、それは収入 の減少や職業的地位の喪失、ひいては社会的剥奪感にもつながる。これらの人々の間では、ハンガリー人の主な 疾患および死因である心血管障害、がん、筋骨格疾患、精神衛生上の問題がより高率に見られる。国内における 平均余命の地域差も著しい。ハンガリー東部と西部の間には明らかな差がある。西部国境沿いに住む人々の出生 時平均余命はとても良い。首都の中でさえ、市内地区のデータを比較すると大きな差が見られる。これらの差は 社会経済的格差と高い相関性があり、年齢層の構成とはそれほど関連がない。このような差は医療サービスへの アクセス可能性にも存在する。一次医療サービスの分野では全国的に医師の数が必要な水準を下回っており、格 差が明らかである。残念なことに、不利な条件の地域の中には、地域で利用できる健康相談サービスがまったく ない村も複数ある。
高齢者人口に重点を置いたハンガリーの健康保険および社会的介護制度 ハンガリーは単一支払者制度を採用しており、中央政府が主要な役割を果たしている。中央政府は、戦略的方 向性を決定し、規則を公布・施行するほぼ排他的な権限を有している。健康保険については、国家健康保険基金 運営機構（National Health Insurance Fund Administration、NHIFA）が健康保険基金（Health Insurance Fund、HIF）を運営しており、これが最も重要な国営の医療基金である。再編の結果、現在は国の総予算に組 み込まれており、政府が直接管理している。ほぼすべてのハンガリー人（95%）がHIFに加入している。2012 年以降、医療制度のもとにある主な機関やサービスの中央（再）集権化が進められている。介護サービスについ ては、社会法（法令3、1993年）に基づき、国および地方自治体が社会的介護（社会的サービス）を提供してい る。地方自治体にサービスを組織する義務がある一方で、NGOおよび教会も参加することができる。ユダヤ人 のホロコースト生存者のためには、よく組織された高齢者介護サービスが国際基金や地域の基金によって運営さ れている。ハンガリーの年金制度では、加入期間20年で受給資格が得られ、月額28,500ハンガリー・フォリン ト（108ユーロ）の最低年金（2013年時点）が支給される。平均拠出額（contribution base）が最低年金額より も低い場合、年金は平均月給額と同額（100%）になる。いずれにしても、この額はEU諸国の平均よりはるかに 低い。
92 高齢者向けの健康促進プログラム EUおよびWHOの2020年までの優先プログラムに従って以下の取り組みが行われている。「格差に立ち向か い」「健康な老い」を実現するため、ハンガリー議会は2009年に「高齢者に関する国家戦略（National Strategy concerning Senior Citizens）」を採択した。いくつかの構想はあるものの、残念ながら現在のところ、効果的な プロジェクトの開始・評価には至っていない。
ハンガリーの地方における社会的介護 前述のように、健康状態および適切な医療や社会的支援へのアクセスに関して言えば、地方住民、特にへき地 の小集落に住む人々は都市住民と比較して不利な状況にある。大抵の場合、地方の自治機関が「デイケア・ホー ム」のようなサービスや社会的支援介護サービスなどを設けている。
要約および要点 • ハンガリーでは実質的にすべての高齢者が健康保険および年金保険制度に加入しているものの、一般的に、健 康状態および医療や社会的介護サービスへのアクセスに関しては大きな格差がある。 • ハンガリーはEUに加盟しており、「高所得国」に分類されているが、国家間または国内での格差が見られる場 合もある。 • 高齢者への社会的介護の分野では、NGO、教会、その他の慈善団体の果たす役割が非常に重要である。
■ REFERENCES / SOURCES OECD/ European Observatory: State of Health in the EU: Hungary; Country Health Profile 2017 Health inequalities and the social determinants of health in Hungary (Az egészség-egyenlőtlenségek és az egészsség társadalmi meghatározói Magyarországon) Summary report of the Health Inequalities and the Social Determinants of Health in Hungary working group, Editors: Éva Orosz and Zsófia Kollányi, Budapest, 2014 J. Sixsmith et al.: Healthy ageing and home: The perspectives of very old people in five European countries, ELSEVIER, Social Science & Medicine 106 (2014) 1-9 Johan P. Mackenbach et al.: Determinants of the magnitude of socioeconomic inequalities in mortality: A study of 17 European countries, ELSEVIER, Health & Place 47 (2017) Marzena Tambor and al.: Health Promotion for Older People in Hungary: The need for more action, Zdrowie Publiczne i Zarządzanie 2017; 15 (1): 96-107 Human rights of older persons in Hungary, Information for the Office of the United Nations High Commissioner for Human Rights on the promotion and protection of the human rights of older persons: https://www.google.pl/ url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwj35d_BufLRAhVrIJoKHQU4A lwQFggcMAA&url=http%3A%2F%2Fwww.ohchr.org%2FDocuments%2FIssues%2FOlderPersons%2FPublicCon sultation2013%2FHungary.doc&usg=AFQjCNFB0E3tfQ6VZYCu_i4Y0veFCXRQFw&sig2=jh6MzPG7KERoGBV -gpFk4g, accessed: 05.03.2018.
略歴：ヘルスサイエンス、中でも内科と公衆衛生学を専門とするMD、PhDであり、2007年ペーチ大学University of Pécs（ハンガ リー）で教授となる。1992年-1996年、ペーチ大学とブダペスト大学の准教授。国際農村医学会IAAMRHには、1986年、Tényi先生 が会長時代に入会した。また1996年、国際移住機関International Organization for Migration（IOM）に、バルカン半島の緊急かつ 紛争後の人道支援を計画立案し調整するために参加。2003年7月23日、タイのAyudhayaでIAAMRHの事務総長に選出された。2004 年- 2007年、IOM European HQでブリュッセルに留まり、移住民の健康に関するヨーロッパのIOM Senior Migration Health Adviserとして働く。2007年ペーチ大学に帰り、教授に就任、Senior Scientific Adviser。移住民や少数民族の健康を守るプロジェク トのキーマンとして働く。2014年、WHOと共同で ‘Healthy ageing of Roma Communities’（ロマ人社会の高齢化と健康）につい て国際シンポジウムを企画した。2016年から、ヨーロッパにおけるWHO Migration Health Strategy and Action Planの実行責任者 となり、2017年3月、ハンガリーのペーチにおいて、European Network of Intercultural Elderly Care（ENIEC）conferenceを主 催した。このため、2017年、欧州議会から‘European Citizen’s Prize’（欧州市民賞）を授与された。詳細はhttp://mighealth-unipecs. com/.を御覧下さい。118本の論文等がある。
93 IARM Keynote Lecture ⑩（Day 2）17 p.m.
Ageing Roma ethnic minority population in Hungary ‒ Challenges, realities, perspectives for the health and social care system Dr. Zoltan KATZ（ハンガリー） Department of Operational Medicine ‒ WHO Collaborating Centre, University of Pecs Medical School, Hungary introduction Population ageing is one of the most important challenges for societies in the 21st century. According to estimations, the number of people in the world aged 60 years or over is projected to grow from 901 million to 1,4 billion between 2015 and 2030. The life expectancy at birth and other health indicators show continuous increase worldwide as well. However demographic trends represent a substantial increase in the number of older persons in most countries, there could be significant differences in demographic indicators on ethnic minority level.
Features of roma population ‒ the main barriers Currently, Roma population forms the largest ethnic minority in Europe. This ethnic group is demographically different from the majority European population. The ancestors of Roma people moved from northern India into Europe between the 9th and 14th centuries. Roma people belong to marginalised communities all over Europe. They face serious social exclusion factors, like worse education level, higher unemployment level and worse housing and living conditions than the majority population. Evidence demonstrates that social exclusion factors are closely linked to numerous barriers in health care context including literacy barriers, discrimination by health care professionals, lack of knowledge of available health care services, physical barriers (mobility and distance), ignoring the importance of prevention programs. According to studies, social determinants of health of Roma are associated with substantially worse health indicators compared to non-Roma: shorter life expectancy at birth (5-20 years shorter), higher infant mortality rate (2-6 times higher), higher prevalence of major infectious diseases, etc. Roma people suffer significantly from illnesses associated with social determinants of health, have a poorer health-related lifestyle (e.g. smoking behaviour, alcohol consumption). These differences are considerable in member states of the European Union (EU) but are not consistent across the EU. On a country level, comparing the health of Roma living in rural settlements with the general population, the difference would be more depressing. All the listed statements are relevant in case of Hungarian Roma population. hungary ‒ country-specific background information In most European countries, health data recording systems do not cover ethnicity. Ethnically disaggregated data collection on non-discriminatory basis works only in the United Kingdom. Available figures and numbers are based on estimates from national reports, region-specific information. Regarding demographic figures, the census is the most reliable data source. The last census represents only those who self-declared themselves as Roma (315.583 people (3,17%) of the Hungarian population). The total number of Roma people is unknown, but according to estimates, the real population size is at least twice as high as the census data. Age pyramid shows that Roma population has higher fertility rate and only a few percent of elderly people aged above 65. Roma population is considerably younger compared to the average population. The life expectancy at birth is 79,2 years for women and 72,4 years for men, but for Roma, it is estimated to be 10-15 years less. Roma Health Report (European Commission) reveals that while the longevity rate – the proportion of people who can expect to reach the age of 75 and over – is 51% for the EU-27 non-Roma population and just 25.7% for the EU-27 Roma population. The fact that Roma are far behind the health and demographic indicators of the majority population is likely to be a result of more difficult access to health services, irregular contact with health practitioners, low socioeconomic status, bad living conditions, unhealthy lifestyle, low education level, etc.
94 social and health care system services ‒ involvement of roma The current retirement age in Hungary is 65, irrespectively for gender. Retired people are entitled to the same health care services than the active working population. The social system in Hungary provides the same services for all retired elderly patients, but the quality of services could highly depend on the given region of the country. People living in rural circumstances have restricted opportunities compared to the urban population. The situation of Roma is more handicapped since they are living under the average socio-economic level of the population. Home care service for retired patients is part of the social network provided by the government, but this service is unable to provide the appropriate and needed support even for the average Hungarian population. Good and best practices are generally initiated by local governments and non-governmental organizations (NGOs). These practices are able to complete the general services in an effective way. Our Department in cooperation with WHO has organized and hosted an expert meeting of 11 EU countries, entitled: Healthy Ageing of Roma Communities. Its declaration, adopted by WHO as well highlights, among others, • combat all forms of discrimination in health systems (direct and indirect, individual and institutional); • develop mainstream policies at the national and local community levels that take into account diversity and counter discrimination and exclusion.
Profile: Assistant professor, University of Pécs, Medical School (UP-MS), Department of Operational Medicine, Chair of Migration Health (under the designation for WHO Collaborating Centre on migration health training and research)
Education and Training graduated as a pharmacist at UP-MS (2009) Postgraduate Educational Program specialized on Patient Care / Pharmaceutical Care (2012) Assistant professor at UP-MS, Chair of Migration Health; (2012 –) PhD student in PhD Program of UP-MS, Topic: The effects of migration on public health safety of the host countries with special focus on the epidemiology of infectious diseases; (2013 –)
Positions, membership: Hungarian Chamber of Pharmacists Hungarian Society of Pharmaceutical Sciences Hungarian Association of Public Health Training and Research Institutes European Public Health Association (EUPHA) Healthcare Leadership and Management Development Institute (HLMDI) European Network on Intercultural Elderly Care (ENIEC)
Scientific experiences: Taking part in education within the frame of the gradual and post-gradual training programs Participating in several European Union (EU) funded projects on migration health related issues: • MSc in Migrant Health (ERASMUS: CHANCE project); • HEALTH MANAGEMENT project (IPA Cross-border Co-operation Programme); • PROMOVAX project (Promoting Migrants’ Vaccination among Migrant Populations in Europe); • ARECHIVIC project (Assisting and reintegrating children victims of trafficking); • RomaHealthNetwork funded by the Open Society Foundation Public Health Programmes Member of the Editorial Office and the Editorial Board of the Public Health Aspects of Migration in Europe WHO Newsletter (PHAME). Taking part in editorial tasks Taking part as a group leader of medical students in a humanitarian mission in Haiti performed in orphanages and schools (2014). The mission focused on medical screening and health education Taking part in the International Visitor Leadership Program (IVLP) – Migration Health Policy in the U.S. (2014) Taking part in seminars like Changing the Narrative on Roma health, Salzburg, (2015) Deputy coordinator of the international symposium on ‘Healthy ageing of Roma Communities’ that was concluded into a statement adopted by the WHO Regional Office (2014) deputy coordinator of the European Network of Intercultural Elderly Care (ENIEC) conference in Pécs/ Hungary (2017)
95 IARM 基調講演 ⑩（第 2 日目）17 p.m.
ハンガリーの高齢化するロマ少数民族 －医療および社会的ケアシステムの課題、現実、今後の展望 Dr. Zoltan KATZ（ハンガリー） Department of Operational Medicine ‒ WHO Collaborating Centre, University of Pecs Medical School, Hungary
緒言 人口高齢化は21世紀の社会において最重要課題の1つである。推定によると、2015年には世界中で9億100万 人だった60歳以上の人の数は、2030年までの間に14億人に増加すると予想されている。出生時平均余命および 他の健康指標も世界的に上昇の一途をたどっている。多くの国において高齢者の人口は著しい増加傾向を示して いるものの、少数民族レベルでは人口指標に大きな違いが見られる場合もある。
ロマ人口の特徴－主な障壁 現在、ロマ人口はヨーロッパ最大の少数民族を形成している。ロマ民族とヨーロッパの多数派人口との間には 人口統計学的な差異が見られる。ロマ民族の祖先は9世紀から14世紀の間にインド北部からヨーロッパに移動し てきた。ヨーロッパ全域において、ロマの人々は社会から疎外されたコミュニティに属している。多数派人口と 比較して教育レベルが低く、失業率が高く、住宅事情や生活環境が劣悪であることが、深刻な社会的疎外の要因 となっている。社会的疎外の要因は医療を受ける上での数多くの障壁と密接に関連しているとの証拠がある。障 壁となるのは識字率の問題、医療従事者からの差別、利用できる医療サービスについての知識不足、物理的な障 壁（移動手段および距離）、予防プログラムの重要性に対する認識不足などである。研究によると、ロマ人口の 健康の社会的決定要因は、非ロマ人口と比較して著しく悪い健康指標と関連している。すなわち、出生時平均余 命が5～20歳短く、乳児死亡率が2～6倍高く、主な感染症の有病率が高いことなどが挙げられる。健康の社会的 決定要因に関連した病気を抱える人は多く、不健康な生活習慣（喫煙行動、アルコール消費など）を持ってい る。欧州連合（EU）加盟国において、これらの差異は相当なものであるが、EU全体で同程度の差異が見られる わけではない。地方集落に住むロマの健康と一般国民の健康を国内レベルで比較すると、両者間の差異はより深 刻である。上述したすべての状況がハンガリーのロマ人口に当てはまる。
ハンガリー特有の背景情報 ヨーロッパの大半の国の健康データ記録制度において、民族性は調査の対象となっていない。差別的でない方 法で民族ごとに分類したデータ収集が機能しているのは英国のみである。入手できる統計や数字は、国家報告書 や地域固有情報に含まれる推定値に基づいている。人口統計データについては、国勢調査が最も信頼のおける情 報源である。直近の国勢調査によると、自らロマであると申告した人は315,583人（ハンガリー人口の3.17%） であった。ロマ人口の総数はわかっていないが、実際の人口は国勢調査のデータの少なくとも2倍であると推定 されている。人口ピラミッドから、ロマ人口では出生率が高く、65歳以上の高齢者は数パーセントであることが わかる。ロマ人口は一般人口と比べてかなり若い。一般人口における出生時平均余命は女性で79.2歳、男性で 72.4歳であるが、ロマの場合は10～15歳短いと推定される。ロマ健康報告書（Roma Health Report、欧州委員 会）によると、長寿率、すなわち75歳以上まで生きると予想される人の割合は、EU 27か国の非ロマ人口では 51%なのに対し、EU 27か国のロマ人口ではわずか25.7%である。 ロマの健康指標および人口指標が多数派人口と比較して大きく遅れをとっている原因は、医療サービスへのア クセスの困難さ、医療関係者と接する機会が不定期であること、社会経済的地位の低さ、劣悪な生活環境、不健 康な生活習慣、教育レベルの低さなどにある可能性が高い。
社会および医療制度サービス ―ロマへの対応 現在、ハンガリーにおける退職年齢は性別に関わらず65歳である。退職者には、現役で働く人と同様の医療 サービスを受ける権利が与えられている。ハンガリーの社会制度では退職高齢者すべてに同じサービスが提供さ れるが、サービスの質は国内の地域に大きく依存する場合がある。地方に住む人々にとっては、医療サービスへ のアクセスは都市住民と比較して限られた機会しかない。ロマの人々は一般人口の平均よりも低い社会経済的レ ベルで生活しているため、状況は一層不利である。退職している患者への在宅介護サービスは、社会的ネット ワークの一環として政府が提供している。しかし、このサービスは、ハンガリーの一般人口に対してさえ適切か つ必要なサポートを提供できていない。大抵の場合、地方自治体や非政府組織（NGO）の主導で優れた取り組
96 みが行われており、これらの取り組みは一般的なサービスを効果的に補完している。 我々の学部はWHOとの協力し、「ロマ社会の健康的な老化（Healthy Ageing of Roma Communities）」とい うテーマで11のEU加盟国の専門家による会議を企画・開催した。WHOによって採択された宣言の中では、以 下の点が特に強調されている。 • 直接的・間接的差別、個人的・組織的差別を含め、医療制度におけるあらゆる形態の差別と闘う。 • 多様性を考慮に入れ、差別や排除に対抗する主流政策を国家および地域コミュニティレベルで策定する。
略歴：Pécs（ペーチ）大学医学部助教授（UP-MS）、Department of Operational Medicine, Chair of Migration Health（under the designation for WHO Collaborating Centre on migration health training and research）。科学的業績につ いては、これまで数々のロマ人健康ネットワーク（Roma Health Network）などEUの移住（移民）の健康問題に関するプロジェクト に参加してきた。Public Health Aspects of Migration in Europe WHO Newsletter（PHAME）の事務所のメンバーであり、雑誌 の編集者である。2014年、医学生の時、ハイチの孤児院と学校にて人道援助活動のリーダーとして活躍した。2017年、ペーチで開催 された異文化交流をベースにした高齢者ケアのヨーロッパ・ネットワーク（European Network of Intercultural Elderly Care （ENIEC）conference in Pécs（ハンガリー）の副コーデイネーター。
97 IARM Keynote Lecture ⑪（Day 3）9 a.m.
Current situation and future prospects of South Korea health insurance systems including the long-term care health insurance for aging people Prof. Kyeong Soo Lee（韓国） Vice-president of IARM, Department of Preventive Medicine & Public Health, Yeungnam Univ. College of Medicine, Daegu, Republic of Korea
Korean medical insurance began in 1977. In 1977, it implemented for workplaces with 500 or more employees, and since 1979, it introduced medical insurance for public officials and private school teachers and staffs. The Korean government continued to extend the coverage of the medical insurance system and implemented the National Health Insurance from July 1, 1989. In 1989, 12 years after starting medical insurance in 1977, the National Health Insurance was introduced. From 1977 to 2000, it operated a cooperative(societies) system of medical insurance. In 1998, it has integrated regional medical insurance and officials and teacher medical insurance. private school teachers In 2000, it has integrated national health insurance management corporation and employee medical insurance association (139 societies). As of February, 20018, the total number of people covered by health insurance in Korea was 50,941,000 (97.1% of the total 52,444,000 people) and 1,503,000 It is the subject of Medicaid. As of 2017, 6,806,000 elderly people aged 65 or older account for 13.4% of health insurance recipients, and 39.9% (27.7 trillion Korean won≒ 2.7 trillion JPY≒ USD 250 billion) of the total wage is 69.3 trillion Korean won≒ USD 600 billon) for the elderly. The rate of increase in medical expenses for elderly people aged 65 or older is twice as fast as that for medical expenses of less than 65. The Long-term Care Insurance regulates items on long-term care benefit, which supports the physical activity or housework for the elderly who have difficulty taking care of themselves due to old age or geriatric diseases. It aims at promoting senior citizens' health and life stabilization as well as improving the quality of people's lives by mitigating the burden of care on family members. (Article 1 of the Act on Long-Term Care Insurance for Senior Citizens)
○ Those eligible: Those over 65 or under 65 with geriatric diseases ○ How to apply: visit, email, or send mail or fax to the National Health Insurance Corporation (Long- Term Care Insurance Management Centers nationwide) ○ Documents to prepare － Application for long-term care assessment, doctor's referral slip (medical certificate), document to prove identity or proxy.
Types of Long-term Care Benefits (Article 23 of the Act on Long-Term Care Insurance for Senior Citizens) (1) In-Home benefits • Visit care, visit bathing, visit nursing, day and night care, short-term care, other in home benefits (welfare equipment) (2) Facility Benefits • Long-term care benefit of providing recipients with training and education to help maintain and improve their physical and mental health for a long period in a welfare medical facility for the elderly managed by long-term care providing institutes according to Article 34 of "Act on Welfare for Senior Citizens"
98 As of the end of 2016, about 6.9 million elderly people are covered by long-term care insurance. Among these elderly people, the number of elderly people applying for long-term care insurance is about 850,000, of which 76.3% (519,850 persons) are eligible for long-term care insurance. 7.5% of the elderly are receiving long-term care services. The financial resources of long-term care services are covered by premiums and some tax. As of the end of 2016, the total cost is about 5 trillion Korean Won (≒ USD 420 billion), an increase of about 70% over four years, compared with the salary of 3.1 trillion Korean Won(≒ USD 250 billion) in 2012. In Korea, it is necessary to strengthen the health promotion and disease prevention policies for the elderly, to prolong the healthy life span and to reduce the elderly medical expenses. However, policies for the prevention of chronic diseases are not sufficient, and most of the policies are focused on treatment policies, so health promotion and disease prevention policy are very necessary.
Profile: Present: Professor of Department of Preventive Medicine and Public Health College of Medicine, Yeungnam University, Daegu Metropolitan City, Republic of Korea. 2016 – Present Vice President of International Association of Rural Health and Medicine (IARM) 2016 – 2017 President of Korean Society for Agricultural Medicine and Community health 2016 – 2017 Chair of Scientific Committee of The Korean Society for Preventive Medicine 2011 – Present Director of Center for Prevention Services, Yeungnam University Hospital Regional Center for Respiratory Diseases Jan. 2009 – Present Editorial member of Health Policy and Management Jan. 2009 – Present Member of Board of directors of Korean Preventive Medicine
99 IARM 基調講演 ⑪（第 3 日目）9 a.m.
韓国の高齢者のための介護保険を含む 健康保険制度の現状と今後の展望 Prof. Kyeong Soo Lee（韓国） 国際農村医学会副会長、嶺南大学医学部 予防医学・公衆衛生学
韓国の医療保険は1977年に始まりました。1977年には500人以上の職場が対象でしたが、1979年から公務員 と私立学校の教職員にも医療保険を導入しました。韓国政府は医療保険制度の適用範囲を拡大し、1989年7月 1日に国民健康保険を発効し、1977年の医療保険開始から12年後の1989年に、国民健康保険が導入されました。 1977年から2000年まで、協同組合（社会）制度によって医療保険が運営され、1998年には、地方の医療保険、 公務員、教師、私立学校の教師の医療保険が統合されました。2000年には国民健康保険管理会社と従業員医療 保険協会（139団体）が統合されました。20018年2月現在、韓国の医療保険の加入者総数は50,941,000人（総 5244万4千人の97.1%）で 1,503,000人が医療費給付対象者です。2017年現在、65歳以上の高齢者6,806,000人が 医療保険受給者の13.4%を占めており、総支給額の39.9%（27.7兆ウォン≒2.7兆円≒2500億ドル）が69.3兆ウォ ン≒600億ドル）が高齢者に支払われています。65歳以上の高齢者の医療費の増加率は、65歳未満の医療費の 2倍です。 介護保険は、高齢化や老人性疾病により、日常の生活が困難な高齢者の身体的活動や家事を支援する介護給付 の項目を規定しています。高齢者の健康と生活の安定を促進するとともに、家族の介護の負担を軽減することに よって人々の生活の質を向上させることを目的としています。
（高齢者介護保険に関する法律第1条） ○対象者：65歳以上の高齢者または65歳以下の老人性疾病患者 ○申請方法：国民健康保険公社（全国の介護保険管理センター）窓口、メール、FAX、 ○準備する書類 －介護査定申請書、医師の紹介状（医療証明書）、身分証明書または代理人証明書。
介護給付の種類（高齢者介護保険法第23条） （1）家庭内給付 • 介護訪問、入浴訪問、看護訪問、昼夜介護、短期ケア、その他の給付（家庭用福祉機器） （2）施設給付 • 法律第34条（高齢者の福祉について）に定める長期介護施設の管理する高齢者の福祉医療施設において、 被扶養者に長期にわたり心身の健康を維持・向上させるための訓練や教育を提供する
2016年末時点で、約690万人の高齢者が介護保険の対象となっています。これらの高齢者のうち、介護保険を 申請する高齢者の数は約85万人、そのうち76.3%（519,850人）が介護保険の対象となっており、高齢者の7.5% が長期介護サービスを受けていることになります。長期介護サービスの財源は、保険料と一部の税金でカバーさ れています。2016年末の総経費は、2012年に3.1兆ウォン（2,500億米ドル）であったのに対し、4年間で約70% 増加し、約5兆ウォン韓国ウォン（4,200億米ドル）となっています。 今の韓国には、高齢者の健康増進や疾病予防の強化、健康寿命の延長、高齢者医療費の削減が必要です。しか し、慢性疾患予防政策は十分ではなく、政策の大部分は治療方針に重点を置いているため、健康増進や疾病予防 政策の強化が求められています。
略歴：韓国・大邱広域市にある嶺南大学の予防医学・公衆衛生学教授 2016 ‒ 現在 国際農村医学会（IARM）副会長 2016 ‒ 2017 韓国農村医学会理事長 2016 ‒ 2017 韓国予防医学会学術委員会会長 2011 ‒ 現在 嶺南大学病院・呼吸器疾患予防地域センター長 2009年1月 ‒ 現在 Health Policy and Management編集委員 2009年1月 ‒ 現在 Korean Preventive Medicineの理事
100 101 IARM Keynote Lecture ⑫（Day 3）9 a.m.
Preparation and Measures for Elderly with Dementia in Korea; Focus on National Strategies and Action Plan against Dementia Moo-Sik Lee MD, PhD（韓国） Department of Preventive Medicine, College of Medicine, Konyang University
Dementia is major epidemic disease of the 21st century in the world. Dementia is one of the major issues in public health globally. Also in Korea, the estimated prevalence of dementia was 8.7%(0.47 million) in 2010, the number will reach the 1 million mark in 2024, it will become a 15.1%(2.71 million) by 2050. Among Koreans aged 65 or older, 725,000 are estimated to be suffering from dementia in 2017. Against dementia, Korea developed three National Dementia Plans in 2008, 2012, and 2016. The 1st plan was came into effect in 2008 and focused on prevention, early diagnostic, development and coordination of infrastructures and management, and improving awareness. The 1st National Dementia plan included the implementation of National Long-term Care Insurance, providing the funding to ensure that every person has timely access to relevant services and support. The National Dementia Early Detection program was also introduced, which all older adults in Korea have access to dementia screening and can access post-diagnostic services including reimbursement for medication if needed. As a result, diagnosis rates have increased to 75%. The 2nd plan was launched in 2012, addressed the same priorities but had a stronger focus on supporting family members. In 2012 the Dementia Management Act established a statutory basis for organization of the National Dementia plans. Under the Dementia Management Act, the government is required to produce a comprehensive plan for dementia every 5 years. The Act also orders that the government should register the dementia patients and collect statistics on epidemiology and the management of the dementia conditions. This has introduced to the ‘Nationwide Study on the Prevalence of Dementia in Korean elders 2008’, the ‘Study on Dementia Prevalence 2012’, and the forthcoming ‘Study on Dementia Prevalence 2016’. The Act also builded institutions to coordinate dementia treatment, care and support. The Dementia Management Act of Korea required the operation of the National Institute of Dementia and Metropolitan/Provincial Dementia Centers to make and carry out dementia management plans throughout the nation. The National Institute of Dementia has a central management center; and coordinates Regional Dementia Center in the 17 regions(13 have been established so far, 4 more are expected to open before the end of 2016). The Dementia Centers provide education to healthcare professionals and conduct research, as well as building and carry out local awareness campaigns, including the Dementia Partners program. Dementia Centers have specialized program for each region. Another program is running the Regional Dementia Council. The Act also mandate to establish Dementia Counselling Centers in every public health center and the National Dementia Helpline. The 3rd National Dementia Plan of 2016 aims to build a dementia friendly community to ensure people with dementia and their carer live well. This plan focus on community-based prevention and management of dementia, convenient and safe diagnosis, treatment, and care for people with dementia, the reduction of the care burden for family care-givers of people with dementia, and support for dementia research through research, statistics and technology. The infrastructure and manpower for supporting Korean patients with dementia are both insufficient. In 2016, 17 local autonomous dementia centers, 45 regional dementia centers and 253 regional dementia counseling centers are operating in basic autonomous organizations. Among the workforce of the national dementia counseling center, there are 677 persons, including doctors, nurses, mental health specialists and social workers, and the number of dementia patients per one person is 957 persons. A total of 332,000 persons in the long-term care institutions related to dementia were found to be 513.2 persons per 1,000 people with dementia. In 2017, Moon‘s government will introduce the "National Dementia Responsibility System," which guarantees most of the burden caused by dementia. The "National Dementia Responsibility System" presented as a presidential election pledge mainly focuses on strengthening national support for dementia
102 costs and expanding related infrastructure. This plan include that the introduction of a ceiling on self-pay for dementia diseases, expansion of the application of dementia care standards through alleviating the support criteria for long-term care insurance for mild dementia, expansion of dementia support centers, expansion of national and public dementia care facilities. It is expected that the new system will drastically reduce the burden of dementia patients and their families, and the national management system of dementia will be firmly established. Moon’s government will inject a 160 billion-won ($143 million) extra budget to set up 205 new dementia care centers nationwide, the ministry said. There are 47 centers currently under operation, 25 of which are located in Seoul. Another 60 billion won will be spent to establish clinics specialized in dementia care within public hospitals. In the meantime, Korea has accomplished many accomplishments by establishing many measures related to dementia and promoting related projects in a short time, but there are still many challenges.
103 IARM 基調講演 ⑫（第 3 日目）9 a.m.
韓国における高齢認知症患者への対応と対策 －認知症に対する国家戦略および行動計画 Moo-Sik Lee MD, PhD（韓国） Department of Preventive Medicine, College of Medicine, Konyang University
世界的に見て認知症は21世紀の主な流行病（epidemic disease）であり、公衆衛生上の大きな問題となってい る。韓国でも、2010年における認知症の推定有病率は8.7%（47万人）であるが、2024年には患者数が100万人 の大台に乗り、2050年までには推定有病率が15.1%（271万人）に達すると予想されている。2017年には、65歳 以上の韓国人のうち72万5000人が認知症患者であると推定されている。 認知症への対応として、韓国では2008年、2012年、2016年に国家認知症計画（National Dementia Plan）が 策定された。2008年に実施された第1次計画は、予防、早期診断、インフラの整備・連携と管理、意識の向上 （improving awareness）に重点を置いていた。第1次国家認知症計画で実施された国民長期介護保険（National Long-term Care Insurance）は、誰もが適切な時に適切なサービスや支援を受けられるようにするための資金 源となっている。国家認知症早期発見プログラム（National Dementia Early Detection Program）も導入さ れ、韓国の高齢者すべてが認知症検査を受けられるとともに、必要であれば医療費の払い戻しを含む診断後の サービスを利用できるようになった。結果として診断率は75%にまで向上した。 2012年に開始された第2次計画も同様の優先課題に取り組むものであったが、家族への支援により重点を置い ていた。2012年には、国家認知症計画（National Dementia Plan）を組織的に実施するための法的根拠として、 認知症管理法（Dementia Management Act）が制定された。認知症管理法のもと、政府には5年ごとに認知症 に関する包括的な計画を作成することが求められる。この法律はまた、政府が認知症患者を登録し、認知症の疫 学および病状管理についての統計データを収集することを定めている。これに基づき、「2008年韓国の高齢者に おける認知症有病率の全国調査（Nationwide Study on the Prevalence of Dementia in Korean Elders 2008）」、「2012年認知症有病率調査（Study on Dementia Prevalence 2012）」、および、近々発表される「2016 年認知症有病率調査（Study on Dementia Prevalence 2016）」が実施された。さらに、この法律のもとで、認 知症の治療、ケア、支援を連携させるための機関も設立された。全国規模で認知症管理計画を策定・実施するた め、韓国の認知症管理法では国立認知症研究所（National Institute of Dementia）および、都市／地域認知症 センター（Metropolitan/Provincial Dementia Center）の運営が定められている。国立認知症研究所には中央 管理センターが設置され、17地域の地域認知症センター（現在までに13か所が開設され、2016年末までに4か所 が開設予定）をまとめている。認知症センターでは医療従事者の教育や研究活動に加えて、認知症パートナープ ログラム（Dementia Partners Program）など地域の意識を高めるためのキャンペーンが計画・実施されてい る。認知症センターは各地域に特化したプログラムを提供している。これに加えて、地域認知症審議会（Regional Dementia Council）も運営されている。認知症管理法はさらに、各保健所に認知症相談センター（Dementia Counselling Center）を設置することや、国立認知症ヘルプライン（National Dementia Helpline）を設置す ることも定めている。 2016年の第3次国家認知症計画は、認知症患者とその介護者（carer）が充実した生活を送るための、認知症 に優しい地域社会の形成を目的としている。第3次計画が焦点を当てているのは、地域密着型の認知症予防およ び管理、認知症患者にとって簡便かつ安全な診断、治療、ケア、認知症患者を介護する家族の負担軽減、研究活 動、統計データ、技術を通じた認知症研究への支援である。 韓国の認知症患者を支援するためのインフラおよび人材は共に不足している。2016年には、主要な自治体組 織において17の地方自治体認知症センター（local autonomous dementia center）、45の地域認知症センター （regional dementia center）、253の地域認知症相談センター（regional dementia counselling center）が運営 されている。国立認知症相談センターには、医師、看護師、メンタルヘルスの専門家、ソーシャルワーカーを含 めて677人のスタッフがおり、従業員1人当たりの認知症患者数は957人である。認知症関連の長期介護施設 （long-term care institutions）には全部で33万2000人のスタッフがおり、認知症患者1000人につき513.2人の スタッフということになる。 2017 年に文政権は、認知症による負担の多くを補償する「認知症国家負担制度（National Dementia Responsibility System）」を導入した。認知症国家負担制度は大統領選挙における公約であり、認知症のコスト に対する国家的支援の強化と関連インフラの拡大に重点を置いている。この計画には、認知症患者の自己負担額 に上限を設ける（ceiling on self-pay for dementia diseases）こと、軽度の認知症患者への長期介護保険（long-
104 term care insurance）による支援の基準を緩和することで認知症ケア基準の適用範囲を拡大すること、認知症 支援センターや国立および公立の認知症ケア施設を拡大することが含まれる。新しい制度により、認知症患者と その家族の負担が大幅に軽減され、国家による認知症の管理制度が確実に定着することが期待されている。 内閣の発表によると、文政権は1600億ウォン（1億4300万ドル）の追加予算を投入し、全国に205の新しい認 知症ケアセンターを開設する予定である。現在は47のセンターが運営されており、そのうち25のセンターはソ ウルにある。さらに600億ウォンを投じて、公立病院内に認知症ケア専門外来（clinics specialized in dementia care）を設置する予定もある。 多くの認知症関連対策を確立し、関連プロジェクトを短期間のうちに推し進めたことにより、すでに韓国では 大きな成果が上がっているが、残されている課題もまだ多い。
105 IARM Keynote Lecture ⑬（Day 3）9 a.m.
Current State of Home Visit Nursing Care in South Korea Eunok Park, RN, PhD（韓国） College of Nursing, Jeju National University
The elderly population of South Korea is 13.6% of the total population in 2016, of which 6% are in financial difficulties as beneficiaries of basic livelihood. According to a survey for the elderly, 89.2% of elderly people have at least one disease and the most common disease diseases among elderly are hypertension (56.7%), arthritis (33.4%), and diabetes (22.6%). In South Korea, there are three ways of home health care; Home visit care at public health center, home visit nursing care as a part of long-term care services and hospital-based home care nursing. Home visit care at public health center started nationwide in 2007 as a customized home visit health care program. Specific steps for this nurse-led home visiting intervention were patterned after the standardized intervention protocol (MHW, 2012a), beginning with an initial start-up interview for problem identification and the scheduling of home visits. Then, a visiting nurse who was the primary interventionist conducted an individually tailored intervention according to an individual’s specific healthcare problems during the scheduled home visits. Primarily, the visiting nurse prioritized participants’ problems and established shared goals for the care and management plans. These home visits provided health education and self-management counseling. As of December, 2016, 1,102,210 households and 1,277,299 people were enrolled in the home visit health care program of public health center, 96.5% of the enrolled people were the elderly over 65 years of age, and 42.2% were the elderly who were living alone. Long - term care insurance was introduced on July 1, 2008 in South Korea. Long-term care services are divided into facilities services and home and community services. Home and community services consist of home visit care, home visit bathing, home visit nursing care, day and night protection, and short-term care. Among the 7,164,725 people aged 65 and over, 886,187 people applied for long-term care insurance as of June 2017, and 552,437 people received long-term care benefits. Of the elderly population, 7.7% received long-term care insurance benefits. There are 14,680 institutions providing home care services and 5,237 residential facilities for long-term care for the elderly. In the first half of 2017, the cost of home visit care accounted for 36.4% of all cost of long-term care services. The cost of home visit nursing care accounted for only 0.2%. Hospital-based home care nursing services is a nursing service that provides nursing care for patients and their families by family nurse specialists. Nursing is provided based on the prescription of doctors for post-operative early discharge patients, chronic patients, chronic obstructive respiratory disease patients, cerebrovascular patients, etc. For providing home care nursing, the hospital should hire two or more family nurse specialists. By 2013, 117 hospitals provide home care nursing. For activation of home visit nursing care, we need to investigate the recognition of the importance of the home visit cares, the standards of the home visit care services and quality control, and institutional standards should be established so that home visit nursing care can be provided on a mandatory basis. We discussed the ways of improving and activating home visit nursing care.
106 IARM 基調講演 ⑬（第 3 日目）9 a.m.
韓国における訪問看護（home Visit Nursing Care）の現状 Eunok Park, RN, PhD（韓国） College of Nursing, Jeju National University
2016年の韓国の高齢者人口は総人口の13.6%にあたり、そのうち6%が生活保護の受給者として経済的困難に ある。高齢者調査によると、高齢者の89.2%が少なくとも1つの病気に罹患しており、最もよく見られる病気は、 高血圧（56.7%）、関節炎（33.4%）、糖尿病（22.6%）である。 韓国の在宅健康ケア（home health care）には、保健所（public health center）による訪問介護、長期介護 サービスの一部としての訪問看護（home visit nursing care）、病院主体の在宅看護（hospital-based home care nursing）の3つの方法がある。 保健所による訪問介護は、それぞれ個人別に訪問健康管理プログラムを作成し、2007年から全国的に開始さ れた。看護師主導の訪問介入の具体的手順は、標準化された介入プロトコル（MHW、2012a）、つまり問題を特 定する最初の開始時インタビューに始まり、自宅訪問のスケジュールを決めるプロトコルに従って定められた。 次に、主介入者である訪問看護師は、スケジュールされた自宅訪問中に個人の特定の健康問題ごとに、各々の事 情に合わせた介入を実施した。まず、訪問看護師は、参加者（高齢者）の問題を優先し、介護とマネジメント計 画の共通の目標を立てた。これらの自宅訪問で、健康教育と自己管理に関するカウンセリングを行った。2016 年12月現在、保健所による訪問健康管理プログラムには、1,102,210世帯、1,277,299人が登録しており、その うち96.5%が65歳以上の高齢者で、42.2%が一人暮らしである。 2008年7月1日、韓国で長期介護保険（long - term care insurance）が導入された。この長期介護サービスは、 施設サービスと家庭/地域サービスに分類される。家庭/地域サービスは、訪問介護（home visit care）、訪問入浴 介護（home visit bathing）、訪問看護（home visit nursing care）、昼夜の見守り（day and night protection）、 短期介護（short-term care）が含まれる。2017年6月時点で、65歳以上の7,164,725人のうち886,187人が長期 介護保険に申請し、552,437人が長期介護給付を受けていた。高齢者人口のうち7.7%が長期介護保険給付を受け ていた。高齢者のための在宅介護サービスを提供する施設は14,680施設、長期介護サービスを提供する居住施設 は5,237施設ある。2017年の上半期では、訪問介護費用は、長期介護サービスの全費用の36.4%を占めていた。 看護師による訪問看護の費用はわずか0.2%であった。 病院主体の在宅看護サービス（hospital-based home care nursing services）は、家庭向け看護スペシャリス トによる患者およびその家族にケアを提供する看護サービスである。看護は、術後早期退院患者（post-operative early discharge patients）、慢性疾患患者（chronic patients）、慢性閉塞性呼吸器疾患患者（chronic obstructive respiratory disease patients）、脳血管障害患者（cerebrovascular patients）などに対して医師の指示に基づ いて行われる。在宅ケアを提供するために、病院は2人以上の家庭向け看護スペシャリストを雇用しなければな らない。2013年までに、117病院が在宅看護サービスを提供している。 訪問看護の活性化のためには、訪問介護の重要性に対する認識、訪問介護サービスの基準とその内容（quality control）に関して調査する必要がある。また、基準にもとづいた訪問看護を提供できるよう、制度を確立する 必要がある。以上、訪問看護の改善と活性化の方法について検討した。
107 IARM Keynote Lecture ⑭（Day 3）14 p.m.
Overview of the post-war Japanese medical care system and prospects of medical and long-term care policies in the advent of an ultra-aging society Prof. Nanako Tamiya（日本） Department of Health Services Research, Faculty of Medicine Research & Development Center for Health Services, University of Tsukuba
Life expectancy in Japan was 83.9 years in 2015, the highest in the world, and its elderly population (those aged 65 and over) has increased rapidly, from 5.6% in 1960 to 26% in 2015, becoming the oldest population in the world. In addition, the elderly dependency ratio was 42% in Japan (compared to the average 24% for OECD countries in 2014), showing a substantially higher proportion of retired persons compared to countries.1 Aging policies started in the 1960s when the post-war Japanese economy started booming. There was great interest in establishing a modern welfare state immediately after the establishment of the National Health Insurance system with universal coverage in 1961. In 1973, started a system of medical care, free for all aged 70 years old and over. As a result, the medical expenditure for inpatient care has rapidly increased, and length of stay ranked the highest among OECD countries.2 The Japanese government implemented the “Gold Plan”, which was a 10-year strategy for the promotion of health and welfare for the aged in 1989, and a “New Gold Plan” in 1994, targeting the expansion of at-home services.3 In response to the change of demands for aged care, the Long-Term Care Insurance (LTCI, ‘Kaigo Hoken’) system was implemented in 2000, as a third pillar of social security, along with pensions and healthcare4. The aim of the LTCI was shifting the burden of family caregiving to social solidarity, cost- sharing via an insurance premium system, and the integration of the medical and welfare services. Long- term care services are available to all citizens aged 65 years and over, who meet the eligibility criteria, and those having age-related diseases. The benefits are composed of prevention benefits and long-term care benefits (home and facility services), but no cash benefits. The number of LTCI users increased from 11% (2000) to 18% (2015) of the elderly population. The diversity of community services, administered through a system of care-managers, and the increasing numbers of users represent the most successful aspects of our nation-wide LTCI. As a pioneering ultra-aged society, Japan has faced challenges through the years. First of all, under a generous universal coverage, there was an increase in health and long-term care costs.5 For example, health spending as a percent of GDP increased from 7.15% (2000) to 10.85% (2016), and LTC spending increased from 0.59% (2000) to 2% (2014)2. Secondly, there is lack of integration between the health and the long-term care system, as the two are organized by separate delivery systems. For example, for older adults aged 75 and over, health insurance is managed by prefectures, while their LTC insurance is managed by municipalities. These separate systems pose difficulties not only for the continuum of clinical care, but also for the creation of scientific evidence and the enforcement of policies by diverse service providers. However, nation-wide LTCI claim data is available, for selected researchers, and it has become a unique resource for the analyses of the LTCI. Thirdly, there is a shortage of educational programs aiming at the multidisciplinary collaboration between geriatrics and gerontology, even though there are care managers who help in coordinating providers and the decision making process by recipients. Finally, there is a shortage of specific services for carers, such as night-time home helpers, respite care, short-stay, as well as insufficient psychosocial interventions for helping family carers4. Over the last decades, there have been several efforts to manage these problems. To guarantee the sustainability of the LTCI, a reform for a “shift to a prevention-oriented system” was implemented. Thus, the New Preventive Benefits (NPB) have been implemented since 2006, along the reforms to promote an independent life for older persons, by means of an ‘integrated community care system’ since 2012. It aims to provide seamless services across the healthcare, long-term care, prevention, housing, and livelihood support services, such as group homes for people with dementia.3 The eligibility for a facility admission
108 under the LTC has become stricter for special nursing homes for the elderly since 2015, and there has been a revision plan for the amount of copayment , by increasing the copayment for high-income groups in 2017.6 In the advent of an ultra-aging society, we need a paradigm shift, going from “providing good care for a single disease to providing good health in the face of multiple diseases”,7 as older people face multiple morbidities, including social needs. In addition, close collaboration between medical and social services becomes imperative. To achieve this ideal, we need evidence-based policy using databases, such as the national LTCI claims data, national medical database, or DPC data, which could be useful tools for measuring the performance of health and LTC system8. Nowadays, the Japanese government is promoting the Data Health Evolution Plan9, a plan to establish a big data set connecting health check- ups, medical care and long-term care in the near future. Then analyses based on this data set and policy making based on these evidences could be the model of the following aged society. Furthermore, we need changes regarding the appreciation for caregiving, in both in the informal and formal sectors, and we also need reforms in our educational programs, to emphasize a patient-centered and population-centered approach, interprofessional and team-based education, and IT-empowered learning.10 In conclusion, Japan has achieved a rapid increase in medical and LTCI coverage, while there is a renewed interest on cost containment and coordination between health and LTC. To achieve better health and a better LTC system in the context of an ultra-aging society, data-based evidence for health and LTCI policy should be top-priority, alongside with a new perspective on the value of caregivers and the medical education system.
■ References 1. OECD. OECD FACTBOOK 2015-2016 2016. 2. OECD. https://data.oecd.org. 2018. 3. Olivares-Tirado P, Tamiya N. Trends and Factors in Japan's Long-term Care Insurance System: Japan's 10- year Experience: Springer Science & Business Media, 2013. 4. Tamiya N, Noguchi H, Nishi A, et al. Population ageing and wellbeing: lessons from Japan's long-term care insurance policy. The Lancet 2011;378:1183-1192. 5. Sasaki T, Izawa M, Okada Y. Current trends in health insurance systems: OECD countries vs. Japan. Neurologia medico-chirurgica 2015;55:267-275. 6. MHLW. 2017 Revision of the Law for Long-Term Care Insurance. Ministry of Health, Labour and Welfare. http://www.mhlw.go.jp/file/06-Seisakujouhou-12300000-Roukenkyoku/k2017.pdf. 2017. 7. Chan M. Dr Margaret Chan addresses gerontology congress http://www.who.int/dg/speeches/2012/ageing_ 20120330/en/. 2012. 8. Jin X, Tamiya N, Jeon B, et al. Resident and facility characteristics associated with care-need level deterioration in long-term care welfare facilities in Japan. Geriatrics & Gerontology International 2018. 9. MHLW. Data Health Evolution Plan. Japan Ministry of Health, Labour and Welfare. http://www.mhlw.go.jp/ stf/shingi/other-jyouhouseisaku.html?tid=408412. 2018. 10. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The lancet 2010;376:1923-1958.
Profile: Professor and Chair Department of Health Services Research, University of Tsukuba, Faculty of Medicine, Department of Health Services Research. Nanako Tamiya is Professor and Chair Department of Health Services Research, University of Tsukuba. With the background experience as Home care and Institutional physician and research career including studying at University of Tokyo (Ph.D.) and Harvard School of Public Health (MSc): majoring Health Services Research. She is focusing on the HSR to improve the Quality of Long-term Care for elderly or disabled. Health Services Research is not well known in Japan yet, and her department is the 1st department officially named HSR. Her Motto is “Think globally, act locally”
109 IARM 基調講演 ⑭（第 3 日目）14 p.m.
戦後日本の医療制度の概要および超高齢化社会が到来する 日本における医療・長期介護政策の展望 Prof. Nanako Tamiya（日本） Department of Health Services Research, Faculty of Medicine Research & Development Center for Health Services, University of Tsukuba
2015年の日本の平均余命は世界最高の83.9歳であった。65歳以上の高齢者人口の割合は1960年の5.6%から 2015年の26%へと急速に増加し、日本は世界の最長寿国となった。さらに、日本の高齢者の依存人口比率 （elderly dependency ratio）は42%で、2014年の経済協力開発機構（OECD）加盟国の平均24%と比較すると、 退職者の割合が諸外国より著しく高いことがわかった。1 高齢化政策は戦後の日本経済が急成長を始めた1960年代に開始された。1961年に国民皆健康保険制度が成立 した直後、現代的な福祉国家を築くことへの関心が非常に高まった。1973年には、70歳以上の高齢者すべてを 対象とした医療費無料化制度が始まった。結果として、入院患者の治療費は急速に増加し、入院期間はOECD加 盟国の中で最高となった。2日本政府は、1989年に高齢者の健康福祉の促進を目的とした10年戦略「ゴールドプ ラン（Gold Plan）」を、1994年には在宅サービスの拡大を目指した「ニュー・ゴールドプラン（New Gold Plan）」を施行した。3 高齢者介護の需要の変化を受け、年金、健康保険と並ぶ社会保障の3番目の柱として、2000年に介護保険制度 Long-Term Care Insurance（LTCI, ‘Kaigo Hoken’）systemが施行された。4介護保険の目的は、介護する家族 の負担を社会的連帯に移行し、保険料制度を通じてコストを分担し、医療および福祉サービスを統合することに あった。65歳以上の国民で、資格基準を満たし、加齢に伴う病気がある人は介護サービスを利用できる。給付に は予防給付および介護給付（在宅および施設サービス）があるが、現金での給付はない。高齢者人口のうち介護 保険利用者の割合は11%（2000年）から18%（2015年）にまで増加した。ケアマネージャー制度によって運営 される地域ごとのサービスの多様性および利用者数の増加は、全国的な介護保険制度の最も成功している側面で ある。 超高齢化社会の先駆けとして、日本は長年にわたり課題に直面してきた。まず、手厚い国民皆保険制度のもと で、保険医療費および介護費は増加した。5たとえば、国内総生産（GDP）に対する保険医療費の割合は7.15% （2000年）から10.85%（2016年）にまで増加し、介護費は0.59%（2000年）から2%（2014年）にまで増加し た。2次に、健康保険と介護保険が別々の給付体制で運営されており、2つの間の統合性が欠けているという問題 がある。たとえば75歳以上の高齢者に関して言うと、健康保険は都道府県が運営し、介護保険は市区町村が運営 している。制度が分離しているため、連続的な臨床ケアが難しいだけでなく、さまざまなサービス事業者を通じ た科学的エビデンスの形成や政策の実施も困難である。ただし、特定の研究者による全国の介護保険請求データ の入手は可能で、介護保険の分析においてまたとない情報源となっている。3つ目に、事業者間の調整や受給者 の意思決定プロセスをサポートするケアマネージャーの存在はあるものの、老年医学と老人学の学際的な協調を 目的とした教育プログラムは不足している。最後に、夜間ホームヘルパー、休息ケアrespite care、ショートス テイなど介護者のためのサービスservices for carersが不足していること、また、介護する家族をサポートする ための心理社会的介入が不十分なことも問題となっている。4 過去数十年間、これらの問題に対処するためにいろいろな取り組みがなされてきた。介護保険の持続性を確保 するため、「予防重視型システムへの移行」が行われた。このため、2006年からは新予防給付が導入され、さら に2012年からは「地域包括ケアシステム」によって高齢者の自立した生活を促進するための改革も実施された。 その目的は、医療、介護、予防、住宅供給、生活支援（認知症患者のためのグループホームなど）を通じてシー ムレスなサービスを提供することにある。3 2015年以降、介護保険のもとで特別養護老人ホームとして施設認可 を受けるための資格基準は厳しくなっている。また、2017年には、自己負担額を改定して高所得者の自己負担 額を引き上げる計画もある。6 超高齢化社会の到来を受けて、「1つの疾患を上手に治療することから、複数の疾患があっても健康を維持して もらうこと」へのパラダイムシフトが必要とされている。7なぜなら、高齢者は複数の病的状態に直面しており、 それには社会的必要性も含まれているからである。さらに、医療サービスと社会的サービスの緊密な連携も欠か せない。この理想に達するには、全国の介護保険請求データ、国民医療データベース、診療群分類別包括払い （DPC）データなどのデータベースを活用した科学的エビデンスに基づく政策が必要である。これらのデータ ベースは、健康保険および介護保険制度の実績を評価するツールとして役立つと思われる。8現在日本政府が推進
110 しているデータヘルス改革計画は、近い将来に健康診断、医療、介護のデータを連結したビッグデータを構築す る計画である。9このデータセットに基づく分析およびエビデンスに基づく政策決定は、日本に続いて高齢化社 会を迎える国にとってのモデルとなるであろう。それに加えて、フォーマル・セクターとインフォーマル・セク ターのどちらにおいても、介護に対する認識を変える必要がある。また、教育プログラムを刷新し、患者中心・ 住民中心の取り組み、専門職種間の学習やチーム基盤型の学習、ITの力を借りた学習を重視する必要もある。10 結論として、日本では健康保険および介護保険の適用範囲が急速に拡大してきた一方、費用の抑制や健康保険 および介護保険間の協調という面に新たな関心が寄せられている。超高齢化社会において健康保険および介護保 険制度の一層の向上を目指すには、健康保険および介護保険政策を決定するためのデータに基づくエビデンス形 成が最重要である。さらに、介護者の価値や医学教育制度を新たな観点で見直すことも必要とされている。
■ References 1. OECD. OECD FACTBOOK 2015-2016 2016. 2. OECD. https://data.oecd.org. 2018. 3. Olivares-Tirado P, Tamiya N. Trends and Factors in Japan's Long-term Care Insurance System: Japan's 10- year Experience: Springer Science & Business Media, 2013. 4. Tamiya N, Noguchi H, Nishi A, et al. Population ageing and wellbeing: lessons from Japan's long-term care insurance policy. The Lancet 2011;378:1183-1192. 5. Sasaki T, Izawa M, Okada Y. Current trends in health insurance systems: OECD countries vs. Japan. Neurologia medico-chirurgica 2015;55:267-275. 6. MHLW. 2017 Revision of the Law for Long-Term Care Insurance. Ministry of Health, Labour and Welfare. http://www.mhlw.go.jp/file/06-Seisakujouhou-12300000-Roukenkyoku/k2017.pdf. 2017. 7. Chan M. Dr Margaret Chan addresses gerontology congress http://www.who.int/dg/speeches/2012/ageing_ 20120330/en/. 2012. 8. Jin X, Tamiya N, Jeon B, et al. Resident and facility characteristics associated with care-need level deterioration in long-term care welfare facilities in Japan. Geriatrics & Gerontology International 2018. 9. MHLW. Data Health Evolution Plan. Japan Ministry of Health, Labour and Welfare. http://www.mhlw.go.jp/ stf/shingi/other-jyouhouseisaku.html?tid=408412. 2018. 10. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The lancet 2010;376:1923-1958.
略歴：田宮菜奈子教授は、筑波大学医学部ヘルスサービスリサーチ分野教授。東京大学、Harvard School of Public Health（MSc） で、Home care、Institutional physician and research career、Majoring Health Services Researchを学ぶ。高齢者や障害者の 長期ケアの質向上にむけたヘルスサービスリサーチ（Health Services Research, HSR）の研究に焦点を当てている。HSRはまだ日本で はよく知られておらず、田宮教授の教室は、日本で最初の公的HSRの教室である。また、彼女のモットーは、“Think globally, act locally” 「物事はグローバルに考え、しかし、行動は地域性を大事にして」である。
111 IARM Keynote Lecture ⑮（Day 3）15 p.m.
Global Challenges to Rural Health & Medicine with special reference to the Elderly in Rural Areas Dr. Ashok Vikhe Patil（インド） Executive Chairman, Pravara Rural Education Society, DIST-AHMEDNAGAR, Immediate Past President of International Association of Rural Health and Medicine (IARM)
The world is going through rapid changes in all areas including technological, scientific, social, environmental and economical spheres. The technological advances have brought about revolutionary changes in our lifestyles, and also changed the Morbidity and Mortality patterns globally. The DALY shows significant changes from the past decade and there is marked increase in Heart diseases, Stroke, Cancers, Road Trauma and Psychological disorders. While the communicable diseases are on the decline, the non-communicable diseases are growing. This scenario is likely to get complex due to Globalization, Climatic Change, Armed Conflicts, Urbanization, Migration and Changing Gender Norms and the increasing in Geriatric population. The population of elderly between 2015 and 2050 over 60 years is expected to double from 12% to 22%. In 2050, 80% of older people will be living in low- and middle-income countries. The pace of population ageing is much faster than in the past. All countries face major challenges to ensure that their health and social systems are ready to make the most of this demographic shift. Rural and remote areas in many countries experience more pronounced population ageing than urban areas and subsequently, have a higher share of older residents. Lower population density and more geographically dispersed populations make it more difficult and expensive to create and maintain a comprehensive service infrastructure as common in urban areas. The paper discusses the various factors that are now important challenges and their impact on Rural and remote Health.
Profile: Immediate Past President, International Association of Rural Health and Medicine (IARM) Chief Executive Officer, Pravara Medical Trust, Pro Vice Chancellor, Pravara Institute of Medical Sciences University, Loni, Maharashtra, India
Expert theme: Rural Health, Health Economics & Financing, Health Policy and Health Sector Reforms, Hospital Administration and Quality Assurance, Reproductive and Child Health, HIV/AIDS, Human Resources Planning and Management, Social Development, Equity and Access, Advocacy and Behavioral Change Communication, Monitoring and Evaluation, Research and Surveys.
112 IARM 基調講演 ⑮（第 3 日目）15 p.m.
地方の健康と医療に関するグローバル課題 －特に地方の高齢者について Dr. Ashok Vikhe Patil（インド） Executive Chairman, Pravara Rural Education Society, DIST-AHMEDNAGAR, Immediate Past President of International Association of Rural Health and Medicine（IARM）（前・国際農村医学会会長）
世界は、技術、科学、社会、環境、経済を含むあらゆる分野で急速な変化に面している。技術的進歩は人々の ライフスタイルに革新的な変化をもたらし、世界中で有病率および死亡率の傾向をも変化させてきた。障害調整 生存年数（DALY）は過去10年と比較して大きく変わり、心臓疾患、脳卒中、がん、交通事故による外傷、精神 的疾患に著しい増加が見られる。伝染性疾患が減少している一方で、非伝染性疾患は増えている。グローバル 化、気候変動、武力紛争、都市化、移住、ジェンダー規範の変化、高齢者人口の増加により、状況は複雑になる 恐れがある。2015年には12%であった60歳以上の高齢者人口の割合は、2050年には約2倍の22%になると予測 される。2050年には、高齢者の80%が低所得国または中所得国に住んでいると考えられる。人口高齢化のペー スは以前よりもはるかに速くなっている。世界各国は、このような人口動態の変動を最大限に活用した保健・社 会制度を整備するという大きな課題に直面している。多くの国において、農村地域および遠隔地の人口高齢化は 都市部の場合より顕著であり、結果として高齢住民の割合も高い。人口密度が低く、住民が地理的に分散してい ることから、都市部に見られるような総合的なサービス・インフラを構築し、維持するのは一層難しく、コスト も高くなる。本稿では、現在重要な課題となっている様々な要因と、それらの要因が農村地域および遠隔地の 人々の健康に与える影響を検討する。
略歴：前会長（国際農村医学会）、Pravara Medical Trust理事長、Pravara Institute of Medical Sciences University副学長、Loni, Maharashtra, インド。専門は、Rural Health, Health Economics & Financing, Health Policy and Health Sector Reforms, Hospital Administration and Quality Assurance, Reproductive and Child Health, HIV/AIDS, Human Resources Planning and Management, Social Development, Equity and Access, Advocacy and Behavioral Change Communication, Monitoring and Evaluation, Research and Surveys.
113
Oral Session
Day 1 October 10 (Wed.)
Venue B (TFT Hall 300) October 10 (Day 1), 10:00 am - 10:32 am Chairman: Atsushi Ueda, Director, East Asia Health Promotion Network Center O-1
Cost of inpatients with foot problems covered by health insurance in Japan and measures against long hospital stay
Jumpei Wato and Shinya Kashiwagi Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine, Japan
Introduction: Many inpatients with foot problems were stuck because they inevitably decline in functional status after receiving surgeries, which means significant economic burden. As for diabetic foot problems or critical limb ischemia, patients found it difficult to go back home or transfer to hospitals within the confines of the residential area due to the time-consuming management to live at home or the lack of beds for long-term care for specific purposes. Aims of the study: Kitasato University Hospital plays an important roll in acute stage treatment. In our study, the factors associated with long-term hospitalization and elevated costs have been examined statistically. The treatments and clinical results have been summarized, and furthermore the result of our efforts reinforcing the support for the patients looking ahead to their post-discharge life has been examined. At last regarding long-term hospitalization are designed on the basis of the statistical data. Material and method: A retrospective study was carried out on 85 patients admitted to the Department of Plastic and Aesthetic Surgery for foot problems between Jan. 2011 to Dec. 2015. Result: Age, peripheral arterial disease (PAD), multiple surgeries and previous revascularization within hospitalization period are the main factors of prolonged hospital stay with diabetes mellitus (DM) and multiple surgeries at risk of prolonged post- operative period. Patients undergoing minor surgery and minor amputation surgery, and major amputations had a mean length of 60 and 49.5 days respectively. Since Apr. 2014, multi-disciplinary meeting and pre-admission meeting has been held for the patients at risk of long-term hospitalization, and as a result a mean length was 58 days before April 2014 and 48 days since April 2014. Conclusions: The hospitalization period might be shortened because of the reinforced support mentioned above. Multi-disciplinary approach to PAD and DM patients could prevent them being hospitalized again or staying longer on readimission.
116 O-2
Confronting the Crisis in Medical Education ~ ICARE: Five measures to support young physicians ~
SungHo(Narihiro) Chang(Chou), Aritaka Matsuyama, Chieko Benitani, Yuko Nakajima, Youichi Koizumi, Atsuhiro Matsuno, Jun Tsuyuzaki, Hideaki Sato, Kentaro Shimada, Takayuki Eizawa, Ryuichi Kai, Kenichi Ito, Kazuki Yochioka and Gotaro Kurasawa Department of Internal medicine, Asama-Nanroku KOMORO Medical Center, Japan
Stress and depression in medical students and young physicians are serious problems. According to a 2015 JAMA publication, 28.8% of 17,560 physicians worldwide screened positive for depression or depressive symptoms. The Dean of Icahn School of Medicine states that excessive pressure to excel and peer comparison are killing young students. Medical education should focus on developing well-rounded doctors. High emotional intelligence is required in the field of rural health and medicine. Are we taking this situation seriously? Depression and suicide should not be considered “personal problems”. A holistic approach is required to stop these tragedies. In the landmark Zion case in the U.S., a young doctor suffering from exhaustion due to overwork made an error and the patient died. The discussion centered around the hospital and medical system, not the medical error. As a result, young physicians’ work was limited to 80 hours per week. The hospital’s overall performance did not deteriorate. Cramming increasing amounts of knowledge into young physicians does not produce superior doctors. We need well-rounded doctors who can work in an interdisciplinary environment and to redefine success. Shift the focus away from exams and emphasize the formation of the whole physician. Young doctors’severe stress is a problem, but the bigger problem is that those around them do not notice the symptoms. ICARE to support young physicians: Interview; Reduce the focus on exams and conduct interviews to obtain a deeper understanding of medical students’ character and potential Collaborate; Emphasize collaboration instead of competition Ask for help; Hire counselors, develop anonymous SNS questionnaires and encourage people to ask for help Reduce workload; Make doctors’health a top priority Encourage; Focus on medical students’strengths and facilitate dialogue to discuss and learn from mistakes We must change our behavior before the problem worsens.
117 O-3
A novel strategy for gastric cancer screening using a mobile van service equipped with trans-nasal endoscopy
Seiji Adachi, Eri Takada, Koki Obara, Yohei Horibe, Tomohiko Ohno, Midori Iwama, Osamu Yamauchi, Koshiro Saito, Shiki Yasue, Yuhei Kojima, Daisaku Hata, Satomi Nagaya, Yumiko Hara, Chizuru Hori, Nao Tsuji and Mayuko Kohno Gihoku Kosei Hospital, Japan
Introduction: Whereas gastric cancer is a serious healthcare problem in Japan due to its substantial morbidity and mortality, population-based gastric cancer screening has widely used for over 30 years, however, its screening rate has not been unsatisfied. Since 2016, gastroscopy as well as gastrography has been approved as its screening method, because a part of people hardly accept gastrography by physical and/or spiritual reasons. Aim and Methods: In order to increase its screening rate, we recently developed a mobile van service, which carries the equipment for trans-nasal endoscopy that is recognized to be human body-friendly. This service could be deployed in underpopulated area and could excavate a lot of residents, who never experienced gastroscopy, in the region under insufficient medical setting. Results: The number of examinees who underwent gastroscopy in 2017, were 1193 (851 in the clinic and 342 in the van) and its screening rate were increased up to 11.38% (compared to 5.01% in 2016). Questionnaire to the examinees revealed that high convenience of this service achieved the elevation of its screening rate. Conclusion: A mobile van service with gastroscopy could provide a new strategy to eliminate gastric cancer-related death, thus leading the beneficial change in the rural medical care.
118 O-4
Emergency medical service in Komono,Japan
Makoto Miki1, Masuo Oohashi1 and Takafumi Kanazu2 1Komono kousei hospital, Japan 2Komono Fire department, Japan
Introduction: Aging society is one of the most serious problems, especially in rural area in Japan. This affects the emergency medical systems in local areas including ambulance service systems. Aims of the study: In this study, we tried to inspect the emergency medical system in our local area and also to research for the problems to treat patients carried by ambulances in our local area and the hospital. Materials and methods: We analyzed the emergency service records of fire department in our local area retrospectively, and also search for records in emergency requests in Komono Kosei Hospital, in the last decade. Results: The population of Komono-cho has increased 3.8% and the peoples over 65 y.o. increased 30.1% in the last decade. The number of the patients carried by ambulances increased from 1,055 (in 2001) to 1,411 (in 2017). However the number of patients carried to our hospital has decreased from 633 (in 2001) to 409 (in 2017). The accept rate for the requests from the emergency services has decreased from 60% to 41.3%. The accept rates in 2017 were 67.4% in the day time, however, only 30.9% in the night time. The reasons to reject the request were 57.2% of technical problems and 36.2% of during other operations in the day time, and 87.7% and 9.4% in the night time, respectively. The number of doctors to treat emergency cases did not change in the last decade, however, the average age of them was getting older from 44.5 y.o. (in 2003) to 57.5 y.o. (in 2017). Conclusions: The number of patients carried by ambulances are increasing in the aging society. However, E.R. service in the local hospital is unsatisfactory. One of the important reasons might be aging of the doctors in ER.
119 October 10 (Day 1), 10:35 am - 11:15 am Chairman: Kenji Kikuchi, Honorary Director, Yuri Kumiai General Hospital O-5
Elderly patients with proximal femoral fracture who return to living at home: comparison of acute care and rehabilitation (kaifukuki) hospitals
Koji Suzuki JA Toride Medical Center, Japan
Introduction: We investigated whether elderly patients treated for a proximal femoral fracture were able to return home. Patients and Methods: Subjects were 834 patients. We defined the acute care hospital group as patients who returned directly home from the acute care hospital and the kaihukuki group as patients who were transferred from an acute care hospital to a rehabilitation hospital. We recorded the number (proportion) of patients who directly returned home. We also analyzed walking ability and the Barthel index (BI). Results: After 2013, the proportion of patients who returned home directly from the acute care hospital fell below 20%. The proportion of patients who returned home directly from the kaihukuki hospital stayed in the 75–85% range. The BI before injury and at discharge was 86 and 76 points, respectively, in the acute care hospital group. Regarding walking ability, the acute care hospital group included patients who walked without an aid before injury or leaving the hospital. In the kaihukuki group, the BI before injury, at admission, and at discharge from the rehabilitation hospital was 85, 56, and 74 points, respectively. In the kaihukuki group, the ability of patients to walk recovered more slowly. Conclusion: Walking ability and BI is important factors for a proximal femoral fracture who were able to return home.
120 O-6
A new scoring model including bladder neck involvement for recurrence in patients with non-muscle-invasive bladder cancer
Naoko Kawamura, Motohiro Fujiwara and Testuo Okuno JA Toride Medical Center, Japan
Introduction: Bladder neck involvement (BNI) has been reported an independent risk factor for progression in non-muscle-invasive bladder cancer (NMIBC). In this study we investigated the impact of BNI on recurrence and developed a new scoring model for recurrence that includes BNI. Materials & Methods: A total of 318 patients underwent transurethral resection of bladder tumor, and were diagnosed with NMIBC. Patients with upper urinary tract carcinoma, primary carcinoma in situ (CIS) were excluded, and 286 patients were analyzed. The clinical variables included were gender, age, primary versus recurrent, urine cytology, tumor number and size, grade, pathologic T stage, concomitant CIS, and BNI. The risk factors for recurrence were evaluated using Cox proportional hazards regression models. The predictive ability of our scoring model was assessed using c-index, and was compared with that of the European Organization for Research and Treatment of Cancer (EORTC) scoring model. Results: BNI was observed in 62 (17%) cases. During follow-up period, 68 (24%) patients experienced a total of 105 recurrences. The median time to recurrence was 36 months. The recurrence probability at three years for the total cohort was 25%, and was significantly higher in patients with a history of BNI (p < 0.001, 49% vs. 19%). In multivariate analysis, T1 stage (hazard ratio [HR] = 2.29), recurrent tumor (HR = 2.06), and BNI (HR = 2.37) were independent risk factors for recurrence. The weight of these three factors was summed to a total score. When patients were divided into three groups according to score, recurrence rates were clearly discriminated (p < 0.001). This scoring model represented the same c-index (0.70) as the EORTC scoring model (0.71). Conclusion: A history of BNI is a significant risk factor for recurrence in NMIBC. This simple scoring model that includes BNI was a useful tool to stratify the risk of recurrence in patients with NMIBC.
121 O-7
AYURVED FOR CANCER IN RURAL AREAS: A HOLISTIC APPROACH
SUKUMAR SARDESHMUKH BHARATIYA SANSKRITI DARSHAN TRUST’s INTEGRATED CANCER TREATMENT AND RESEARCH CENTRE, WAGHOLI, PUNE, India
Abnormal growth of body cells leads to carcinoma according to modern medical science. ‘Cancer’ is not directly mentioned in Ayurvedic text as one disease. Many diseases, which are described in Ayurvedic text, show similarity with Cancer. Etiology (Nidan), Pathogenesis (Samprapti) and Treatment (Chikitsa) of cancer can be described by considering the Basic Principles of Ayurved. Ayurved, being a holistic science with universal fundamentals and can be aptly implemented to understand this dreadful disease. The retrospective approach for correlating awful diseases mentioned in Ayurved can be implemented to understand cancer. Thousands of formulations have been mentioned in such diseases which can be studied for efficacy. Many plants mentioned in Ayurved have shown anti-cancer, anti-oxidant, anti-inflammatory and immune- modulatory effects. The Ayurvedic methods of body detoxification, diet planning, personal hygiene and lifestyle modifications help both to prevent and treat various diseases. Clinical studies have shown good results in improving quality of life, diseases free survival and preventing recurrence in cancer patients. Thus Ayurved can be helpful to treat Cancer as adjunct treatment modality in cancers like CA oral cavity, CA cervix, CA liver, CA breast etc. which are predominantly found in rural areas. The natural healing techniques of Ayurveda will be helpful to reduce risk and treatment burden extensively.
Key words: Ayurved, Cancer, Rural health, Adjunct treatment
122 O-8
Empirical Study of homelessness and rapes in destitute mentally ill women found on Indian roads and in rural area.
Rajendra Dhamane, Sucheta Dhamane and Vasant Desale NNG INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES, India
In rural India many mentally ill women are abandon by their family members on Indian roads and religious places to die. Mental illness is stigmatized situation for rural population. Many type of mental illnesses found in rural women including schizophrenia, bipolar disorder, depression and anxiety. Family members spurn them leading to homelessness. 90% women are raped and gang raped on road leading to unwanted pregnancies and many sexually transmitted diseases including HIV AIDS and syphilis. Childbirth is again most challenging hurdle. Recovery from mental illness gives them again pain, as women are not accepted and reunited back in their families. This study is conducted in MAULI HOUSE. MAULI HOUSE is a pioneering charitable institute in India providing lifelong home, care, treatment and rehabilitation for these women. This study includes 120 women who are recovered from mental illness and not accepted by their families. Each case is studied thoroughly taking case history and maintained profile from the period since admitted in institute. In this study detail questionnaire was given to each subject to evaluate the possible causes of their mental illness, family history and their experiences when they were living on roads. Detail in camera interviews were taken to understand the scenario. Conclusion of the study shows multiple causes of mental illness including broken families, postpartum psychosis, poverty, illiteracy, religiousness and superstitious ideas. Lack of awareness, treatment and social security is again the prime concern. This paper should help to understand the causes of homelessness and rapes in destitute mentally ill women found on Indian roads and rural area. It will give new insight for remedial measures to overcome the problems and a road map to stop abuse on these women and their children.
Keywords: Rural area, homeless raped women.
123 O-9
Difference of health status and individual level social capital between participants and non-participants to agricultural development project among rural older adults in Japan
Yugo Shobugawa1, Hiroshi Murayama2, Takeo Fujiwara3 and Shigeru Inoue4 1Niigata University, Japan 2University of Tokyo, Japan 3Tokyo Medical and Dental University, Japan 4Tokyo Medical University, Japan
Introduction: In Japan, agricultural development project (ADP) is undertaken to maintain origin of food supply and many functions such as recharging water, maintaining diversity of nature life, creating beautiful landscape, carrying on the traditional culture etc. However, health or behavioral impact on people who join the ADP is not investigated. In this study, to evaluate health status and neighborhood relationship in participants of ADP, we conducted questionnaire survey in rural city in Japan. Methods: Data were drawn from the NEIGE Study, a prospective cohort study of community-dwelling individuals aged 65–84 years living in Tokamachi City, Niigata Prefecture, Japan. The baseline survey was conducted in 2017 and included 527 independent older people (249 men and 278 women; average age 73.6 + 5.6 years). Self- rated health and depressive status measured by geriatric depression scale (GDS) were used as health outcome variables. Neighborhood relationship namely trust, reciprocity, attachment, and communication with neighbor were also set as outcome variables. Participation in the ADP from the NEIGE survey was set as explanatory variable. Age and sex were adjusted. Logistic regression or ordinary logistic regression model was used to study association between participation in ADP and health status and neighborhood relationship. Results: Among the study population (n=527), 113 (21.4%) were participants to ADP. The remaining 414 were non-participants. Participants were significantly less depressive than non-participants (OR:0.40, 95%CI:0.18-0.91). Self-rated health was not different between them. Participants showed significantly higher trust (OR:2.19, 95%CI:1.09-4.39), higher reciprocity (OR:2.04, 95%CI:1.17-3.56), higher attachment (OR:2.42, 95%CI:0.95-6.18), and tighter communication with neighbor (OR:3.69, 95%CI:1.05-13.02) than in non- participants. Discussion: Participants in ADP might actively commit to their community. As a result, their neighborhood communication, trust, attachment, and reciprocity might be higher. Also, such active people do not tend to be depressive. Possible positive effect of ADP was found on health even causal relationship is not sure.
124 October 10 (Day 1), 11:20 am - 11:52 am Chairman: Hiroshi Nagami, Director, Institute for Prevention of Pesticide Adverse Effect on Human O-10
Impact of public expense for the vaccine covered by rural governments on an epidemic of rotavirus enteritis
Yuko Sato1, Yoshiaki Sasaki2 and Hiroki Kajino2 1Department of Microbiology, Fukushima Medical University School of Medicine, Japan 2Department of Pediatrics, Abshiri-Kosei Jeneral Hospital, Japan
Introduction: Rotavirus (RV) is the leading cause of severe acute enteritis in children. The universal vaccination programs for RV enteritis have been introduced in many countries. Although it has not yet been done in Japan, there are children who can receive the RV vaccine at public expense covered by their rural governments. An epidemic of RV enteritis occurred from April to July 2015 in a wide range of regions neighboring our hospital. Children in the regions of Shari and Koshimizu received the RV vaccine at public expense covered by the rural governments, while children in Abashiri received it at their own expense. This study examined the RV vaccine effectiveness (VE) against hospitalization rate and the impact of public expense for the RV vaccine on this regional epidemic of RV enteritis. Methods: All children under the age of 3 years in the regions were participated to this study. Among them, we counted the number of children who received the RV vaccine from January 2012 to July 2014 and the number of hospitalized children due to RV enteritis from April to July 2015. The VE was calculated using test-negative design, a kind of case control study. Results: The vaccination rate was significantly higher in children in Shari and Koshimizu than in Abashiri (93.8% vs. 44.2%, respectively, p<0.001). The RV enteritis- related hospitalization rate was relatively lower in children in Shari and Koshimizu than in Abashiri (1.8% vs. 3.3%, respectively, p=0.13). In addition, the RV VE against the hospitalization rate was 91.1% (95%CI 71.6-97.2%), which is as high as the VE reported in the developed countries. Conclusion: The public expense for the RV vaccine covered by rural governments would be of benefit to children against hospitalization as it increases the vaccination rate.
125 O-11
Our challenge to nurture community-oriented young doctors through overseas primary health care training in collaboration with a medical school in Leyte Island, the Philippines
Jumpei Hasumi, Masahiro Zakoji, Masahiko Sakamoto, Tetsuro Irohira, Akihiro Kitazawa and Kazuya Yui Saku Central Hospital, Japan
Introduction: It is important to nurture community-oriented young doctors, while the effective methods have not been firmly built. Saku central hospital, situated in rural Nagano, has suffered from shortage of doctors and tried to establish a medical school to nurture doctors who serve in rural areas in 1970s. Though the challenge was not realized, many young doctors have continuously come to our hospital to learn community medicine and global health. As a general problem in Japan, doctors are little aware of their communities to serve, thus there has been a demand for a program to inspire their awareness. Aims of the study: Under the Memorandum of Understanding on human resource exchange with School of Health Sciences (SHS) in the Philippines in 2015, we started sending our residents annually to SHS in 2017. The main aim of this program was to encourage them to have spirits and ideas to serve local communities. The senior doctors lead the program in 2018 for assessing its educational impact. Material and methods: The orientation session covers the history of SHS and its community-oriented curriculum. Then the residents accompany the students and graduates into communities and understand how effectively it has distributed health manpower to local communities. They are also informed of our past challenge of establishing a medical school in Saku area. Through this program, they learn efforts to grow community-oriented human resources for health in both countries. Results: As we have not set a quantified outcome, the assessment is subjective. All the residents who joined the overseas training were satisfied with new experiences and came to realize the importance of understanding community and its needs. Conclusions: Though the overseas training does not directly contribute to gaining human resources in the short term, it was suggested fruitful in reforming consciousness of young doctors towards communities.
126 O-12
HIGH RESOLUTION COMPUTERIZED TOMOGRAPHY (H.R.C.T.) FOR PULMONARY CHANGES IN SMOKE INHALATION IN A RURAL POPULATION
DAYANAND SHETTY1, SUNDEEP SALVI2, BILL BRASHIER2, SATISH PANDE1, TEJASWI THAMATAM1, SMITA KORI1 and SAJID TAMBE1 1K.E.M HOSPITAL, PUNE, India 2CHEST RESEARCH FOUNDATION, India
Objective of the study was to document the spectrum of pulmonary changes using HRCT in study and control groups. We quantified the emphysematous changes according to the types of smoke exposure. Materials and methods: Out of 150 subjects, 52 (34.6%) were cigarette smokers, 64 (42.7%) had history of biomass fuel exposure, 34 (22.7%) were neither cigarette smokers nor had history of biomass fuel exposure. Age of the subjects ranged from 45 – 85 years. Results: HRCT spectrum shows predominantly emphysema which includes seven different subtypes as follows: Only centrilobular emphysema (34.9%), only panlobular emphysema (7.76%), Only paraseptal emphysema (1.94%), Centrilobular with paraseptal emphysema (7.76%), Centrilobular with panlobular emphysema (13.5%), Panlobular with paraseptal emphysema (0.97%) and all three types of emphysema (7.76%). Other than emphysema, patchy air trapping and scarring are the most commonly observed findings. CONCLUSIONS AND RECOMMENDATIONS: In my study, spectrum of HRCT findings were emphysema, interstitial lung disease, bronchiolitis and hypersensitivity pneumonitis. Among these, emphysema was the most common pathology seen. Biomass fuel exposure is an important factor causing emphysema and also scarring which is less seen with exposure to smoke. HRCT chest is recommended for subjects with deranged pulmonary function tests and those exposed to biomass smoke and having respiratory symptoms and deranged PFT’s for diagnosis of type and quantification of emphysema. My study shows prevention of exposure to biomass to fuel smoke by improving ventilation of rural kitchen is a must to prevent emphysema particularly in women from rural areas. It also confirms that smoking is highly risky and leads to incidence of emphysema.
127 O-13
Type of Rehabilitation Gardens in Sweden with Development of Nature Based Rehabilitation in Japan
Mayuko Ishii1, Chikako Haruki, Patrik Grahn2, Shin-ichiro Sasahara3 and Yasuhito Hirai 1Medical Corporation Shikoukai, Takase Clinic, Japan 2Department of Work Science, Business Economics and Environmental Psychology, Swedish University of Agricultural Sciences, Sweden 3Faculty of medicine, University of Tsukuba, Japan
People who leave work or take a leave of absence from work that due to illness caused by stress are serious social problems in Japan. Even if they return to work, stress tolerance is weak, and many people repeat stressful diseases many times. It is necessary to have a place and recovery time suitable for restoring stress and to look back and understand themselves. However, the social reintegration system is not sufficient. In Sweden, NBR (nature based rehabilitation) is adopted as a method of physical and mental rehabilitation. It uses nature’s potential effectively and improves human function. NBR is a rehabilitation garden that consists of effective elements of treatment. In this study, we reveal the characteristics of three different rehabilitation gardens compared with Alnarp Method and rehabilitation garden established at the Swedish University of Agricultural Sciences Alnarp campus. From the interviews and surveys collected from other fellow therapists, we use the rehabilitation garden in Japan. It was aimed to obtain knowledge about the possibility of developing NBR. Three different places are located in the suburbs of neighboring prefectures in major urban areas, where tranquility and safety are secured. In places aimed at stress-care such as burnout, emphasis was placed on tranquility and security. A treatment was conducted in a way that did not focus on the suffering of the participants. In places aimed at social adaptation and work preparation, we utilized natural places and functions, and bring out their sociability with others. The rehabilitation garden utilizing NBR also uses local farmers and empty houses, it is easy to accept even those who have difficulty adapting to society when returning to their workplace. In Japan, tranquility, security, oldness, etc. are more valuable, it was suggested that it might be reviewed as something of.
128 Poster Session
Day 2 October 11 (Thur.)
TFT Hall 1000 October 11 (Day 2)
Posters will be displayed between 9 am to 6 pm on Day 2, Oct.11, Thur. Tours for poster presentations are not provided in this IARM poster session. The presenters of the displayed posters will be available for questions and answers on Day 2, Oct.11, Thur. 4 pm-5 pm.
P-1
Attitudes toward death and preparations for death among the community dwelling elderly in Japan
Michiko Sato-Komata1, Akiko Hoshino2, Mai Ogura1, Nobuhito Ishikawa1 and Toshiki Katsura1 1Preventive Nursing, Department of Human Health Sciences, Graduate school of Medicine, Kyoto University, Japan 2Public Health Nursing, Graduate School of Nursing for Health Care, Kyoto Prefectural University of medicine, Japan
Introduction: One of the Japanese elderly’s biggest concerns is SHU-KATSU, which means making preparations for death in their end of life. It is important to reflect on their own life and concern about the death and the end of life as a part of life1). However, there are few studies about concerns and preparations for death. Aims: The purpose of this study is to understand the current state of attitudes toward death and preparations for death among the community dwelling Japanese elderly. Methods: This study was conducted in Niigata and in Kyoto. Self-report questionnaires were given to 65 years over community dwelling people through neighborhood associations. In questionnaires, we asked age, sex, the place wished for on death and dying, preparations for death, and attitudes toward death using scale of DAP for Japanese. Ethical approval (R0927) for this study was obtained. Results: 2772 participants completed questionnaires and we used 1971 questionnaires (Niigata, 73.8%; Kyoto, 26.2%), which met the inclusion criteria, for analysis. There is no significant difference in average age and sex ratio between Niigata and Kyoto. The proportion of elderly who want to die at home was significantly larger in Niigata (62.3%) than in Kyoto (58.1%). And the proportions of elderly who told about the desired way of own funeral, the contact addresses when they die, and the end-of-life medical care as preparations for end-of-life in Kyoto, were larger than those in Niigata. Two dimensions of DAP (Neutral Death Acceptance and Escape-Oriented Acceptance) in Kyoto and Niigata thus differed. Conclusions: We studied, for the first time, the state of preparations for death in the community dwelling elderly, finding that about half of the elderly prepare for death in Japan.
1) Nagae H. Practical nursing of end-of-life care. 1st ed. Japanese Nursing Association Publishing Company, Tokyo, 2014; 2-9(in Japanese).
130 P-2
Risk Factors related to Low Physical and Mental QOL of Elderly Japanese resided in a Rural Town, Ehime, Japan
Mai Ogura1, Michiko Komata-Sato1, Nobuhito Ishikawa1, Akiko Hoshino2 and Toshiki Katsura1 1Department of Human Health Sciences Graduate School of Medicine Kyoto University, Japan 2Graduate School of Health Science and Nursing Kyoto Prefectural University of Medicine, Japan
Purpose: The aim of this study is to clarify the risk factors related to low physical and mental QOL of healthy elderly people living in a mountainous town, Ehime, Japan. Methods: Questionnaire was distributed to 2,882 elderly subjects in January 2017. Survey items were attributes, physical and mental QOL, physical, mental and social frailty, incidental and intentional social isolation, lifestyles and so on. To clarify the risk factors related to low QOL a univariate analysis and multivariate analysis as the analytical methods were used with the statistical software SPSS ver.24.0 for Windows; the significance level was below 5%. This study was conducted after obtaining the approval of the medical ethics committee of Kyoto University. Results: Subjects of analysis were 1,248 responders of questionnaire. When low physical QOL was the dependent variable, a significant correlation was seen for age, marital status, employment, history of current illness, Locomo 5, GDS, GOHAI, HPI, and LSNS. Locomotive syndrome showed the largest odds ratio (OR). For the social isolation classification, when non-social isolation was entered as the standard, a significant correlation was seen with accidental social isolation only (OR significantly less than 1). When low mental QOL was the dependent variable, a significant correlation was seen with ULS-6, Locomo 5, MNA-SF®, GDS-S-J, LSNS, GOHAI, and the number of remaining teeth. The largest OR was for depressive tendency. In the social isolation classification, when non-social isolation was entered as the standard, a significant correlation was seen with incidental social isolation only (OR significantly less than 1). Discussion: Physical, mental and social frailty were related to low QOL. Health promotion activities for elderly residents need to be implemented in even a rural area with rich social ties.
131 P-3
Risk Factors related to Social Isolation of Elderly Japanese resided in a Rural Town, Ehime, Japan
Toshiki Katsura1, Mai Ogura1, Michiko Momata-Satoh1, Nobuhito Ishikawa1 and Akiko Hoshino2 1Department of Human Health Sciences Graduate School of Medicine Kyoto University, Japan 2Graduate School of Health Science and Nursing Kyoto Prefectural University of Medicine, Japan
Purpose: The social isolation of the elderly in Japan has resulted in narrowing of social networks and decreasing opportunities for social exchange. So the aim of this study is to clarify the risk factors related to social isolation of healthy elderly people living in a mountainous town, Ehime, Japan. Methods: Questionnaire was distributed to 2,882 elderly subjects in January 2017. Survey items were attributes, social isolation, physical and mental QOL, physical, mental and social frailty, lifestyles and so on. To clarify risk factors related to social isolation a univariate analysis and multivariate analysis as the analytical methods were used with the statistical software SPSS ver.24.0 for Windows; the significance level was below 5%. This study was conducted after obtaining the approval of the medical ethics committee of Kyoto University. Results: Subjects of analysis were 1,248 responders of questionnaire. When social isolation was the dependent variable, in the multiple logistic regression analysis, using the onset of social isolation as the dependent variable, odds ratios significantly higher than 1 were found for the following variables: non-participation in social activities (OR: 2.10), seclusion (2.03), not having a spouse (1.97), being male (1.78), depressive tendency (1.62), and a strong sense of loneliness (1.22). Risk of cognitive function decline (0.63) was the only variable with an odds ratio significantly lower than 1. Discussion: The multivariate analysis indicated that while physical function was not an associated factor and depression was a main associated factor, the risk of cognitive function decline seemed to inhibit the onset of social isolation. Maintaining a socially independent life would not be possible in the presence of depression or cognitive impairment.
132 P-4
Nursing Practices for Fall Prevention in Hospitalized Elderly Patients with Dementia
Miki Fukuma Department of Nursing, Faculty of Medicine, Shimane University, Japan
Objective: Given that fall prevention is an important safety issue for hospitalized elderly patients with dementia, we aimed to clarify the methods used by nurses for fall prevention in these patients. Methods: Semi-structured interviews were conducted with 10 experienced nurses (at least 3 years’ experience), and their responses were subject to qualitative inductive analysis. The study was approved by the Nursing Research Ethics Committee of the Faculty of Medicine, Shimane University. Results: The analysis resulted in the creation of 141 codes, 33 subcategories, and 10 categories. The 10 categories were related to patient details, nursing assessment, and nursing care for fall prevention. First, nurses sought to understand the patient by assessing the patient’s lifestyle and situation (category 1), risk of movement (category 2), and cognitive function (category3). Then, nurses assessed the factors leading to falls (category 4) and the influence of a patient’s illnesses (category 5) from the previous information. The nurses also explored the meaning of leaving bed (category 6) when patients were unable to communicate. Finally, the nurses sought to support patients to make the best use of functions that were maintained (category 7) to adjust their lifestyle pattern (category 8) and to the hospital environment (category 9). Through such intervention, the nurse dealt with fall risk as a whole (category 10). Conclusions: Fall prevention strategies employed by nurses for elderly patients with dementia involved examining risk factors from physical, psychological, and social perspectives, including the patient’s normal living situation and pattern. Nurses emphasized the importance of understanding patient behaviors and of preparing for a patient’s usual living behavior and environment. This work was supported in part by JSPS KAKENHI Grant no. 17K1215.
133 P-5
Serial changes in Trail Making Test score in patients with mild ischemic stroke
Zen Kobayashi, Miho Yoshioka, Keisuke Inoue, Mayumi Watanabe, Kaori Kato, Kazunori Toyoda, Yoshiyuki Numasawa, Shoichiro Ishihara, Hiroyuki Tomimitsu and Shuzo Shintani JA Toride Medical Center, Japan
Background: The Trail Making Test (TMT) is widely used as a measure of attention impairment. Prolongation of the time needed to complete the TMT has been reported to be associated with driving impairment in patients with brain diseases. Thus far, however, there have been no reports of serial changes in the TMT score in patients with mild ischemic stroke. Methods: We retrospectively investigated serial changes in the TMT score of acute ischemic stroke patients who showed an NIH stroke scale score of 4 or lower and were admitted to our hospital from 2016 to 2017. We included patients in whom the TMT could be performed both 4-11 days after onset (initial evaluation) and 14-61 days after onset (second evaluation). Results: The mean age of the 29 patients was 68.7 years old. The five patients could not complete TMT-B within 300 seconds. The mean completion time of the 29 patients for the initial TMT-A was 64 seconds, and that of the 24 patients for the initial TMT-B was 150 seconds. The completion times for TMT-A and TMT-B were prolonged in 34 and 46% of patients, respectively, when compared with reference ranges. The mean completion times of the 29 patients for the second TMT-A was 50 seconds, and that of the 24 patients for the second TMT-B was 124 seconds. The rates of the patients showing a reduction in the completion time for TMT-A and TMT-B of 10% or more were 66 and 67%, respectively. Conclusion: This study demonstrated that a significant proportion of mild ischemic stroke patients showed prolongation of the completion time of the TMT, and that the completion time shortens in approximately 60% of patients 14 days or later after onset.
134 P-6
A Study on Oral Health of Korean National Basic Livelihood Recipients
Chang-Suk Kim Department of dental hygiene, Ulsan College, Korea
Objectives: The purpose of the study is to provide basic data for oral health promotion in national basic livelihood recipients. Methods: The data were extracted from the 4th National Health and Nutrition Survey(2007-2009) in Korea. The data were analyzed using SPSS 18.0. to χ2-test and CSGLM. Results: 1. The subjects were not able to receive dental treatment because of the financial difficulty. 2. The influencing factors of DMFT include gender, type of health insurance, frequency of tooth brushing, smoking, drinking. 3. The influencing factors of CPI include age, income and use of accessory oral hygiene products. Conclusions: It is necessary to provide oral health care and health promotion to the recipients of National basic livelihood recipient. The government must give them better quality of dental health care in the near future.
135 P-7
Relationship between the patient's level of income and centralization of medical service utilization in cardio-cerebrovascular disease
Min-Ah Nah1, Kyeong-Soo Lee1, Chang Suk Kim2, Sang Won Kim1, Tae-Yoon Hwang1 and Chang-Yoon Kim1 1Department of preventive medicine and public health, Yeungnam University, College of Medicine, Korea 2Department of dental hygiene, Ulsan College, Korea
BACKGROUND & OBJECTIVE: One of the problems of the medical delivery system in Korea is the phenomenon that the patients flock to Seoul. This study analyzed the association between the level of income of patients who live in five major metropolitan areas in Korea and concentration of medical service utilization to Seoul beyond their catchment area as to cardio-cerebrovascular diseases. METHODS: We used the medical examination data of the medical institutions that were requested to the National Health Insurance Corporation for reimbursement of the patient’s medical expenses from January 2003 to December 2013. Data were extracted from the treatment data for 10 years using the diagnostic code and operation code related to cardio-cerebrovascular disease. RESULTS: In most cases, the higher the income level, the higher the rate of surgery in Seoul. Especially in case of coronary bypass surgery, valve replacement, catheter ablation, vascular intervention, the rate of treatment and surgery was higher in Seoul than in catchment area as the income level increased in more than three of five metropolitan cities. Unruptured cerebral aneurysm also had a higher rate of surgery in Seoul as the income level was higher in all five metropolitan areas. Other cerebrovascular diseases were not significantly associated with the level of income and the rate of treatment in Seoul. CONCLUSIONS: In elective surgery, the higher the income level, the higher the rate of surgery in Seoul than in the residential area, and the emergency surgery was mostly performed in the residential area regardless of the income level.
136 P-8
Feasibility of endoscopic screening for upper gastrointestinal malignancies in a complete medical checkup
Sayaka Sato, Yohei Horikawa, Hiroya Mizutamari, Nobuya Mimori, Yuhei Kato, Masayuki Sawaguchi, Saki Fushimi and Syunji Okubo Hiraka General Hospital, Korea
Background: Since several reports revealed mortality reduction from gastric cancer, endoscopic screening has been introduced as the nationwide screening program from 2014 in Japan. Otherwise, recent developments of high-definition endoscopic imaging and diagnostic strategy enables to simultaneously detect other upper gastrointestinal (U-GI) malignancies. Therefore, we conducted a study to evaluate the feasibility of endoscopic screening for U-GI malignancies in a complete medical checkup. Method: We retrospectively assessed the data of participants who received a complete medical checkup program in a single institution between April 2012 and March 2016. They were divided into two groups: gastrointestinal endoscopy (GIE) group and gastrointestinal X-ray (X-ray) group, and compared with regards to detecting rate of U-GI malignancies. In addition, clinical outcomes of participants with U-GI malignancies were analyzed. Result: A total of 9417 participants in five years were assessed. 6331 and 3086 individuals were assigned to GIE group and X-ray group, respectively. There were no statistically significant differences in sex and age between the two groups. However, detecting rate of U-GI malignancies was significantly higher in GIE group 30/6331 (0.47%) compared with X-ray group 1/3086 (0.03%) (P = 0.0005). All participants with U- GI malignancies consisted of 25 gastric cancers, 2 esophageal cancers, 2 duodenal cancers, 1 pharyngeal cancer and 1 duodenal GIST, were curatively treated and survived. Six U-GI malignancies except for gastric cancer were detected only in GIE group. Conclusion: This study indicated the feasibility of endoscopic screening for U-GI malignancies including gastric cancer in a complete medical checkup compared with X- ray examination.
137 P-9
Significance of airborne pollen measurements as a tool to prevent Japanese pollinosis at the community level in Japan
Hidetoyo Teranishi Toyama Kyoritsu Hospital, Toyama Health Cooperative, Japan
Introduction: Japanese cedar pollinosis (allergy to Japanese cedar: Cryptomeria japonica D. Don) has been rapidly increasing in Japan. A committee was organized by the Toyama Prefecture Medical Association to prevent such pollinosis in 1995. The committee supported an atmospheric pollen survey and registered the number of outpatients with pollinosis treated in otolaryngology clinics and ophthalmology clinics. They also performed information services. We analyzed the relationships between the total annual pollen counts and the number of pollinosis patients, and examined the usefulness of measuring airborne pollen for pollinosis prevention. Materials and methods: An airborne pollen survey was performed using a Durham sampler and a Burkard spore trap. Pollen observation sites were set up in several regions, including the University of Toyama. Statistical analysis was performed using the logarithmic transformation of the pollen counts. Results: The annual number of pollinosis patients correlated with the annual total pollen counts. A significant correlation (R = 0 .77) was obtained between the total pollen counts and the number of pollinosis patients. When the total pollen counts reach 4,000, the number of patients is predicted to be 3,700-4,200 based on the regression equation obtained. Conclusion: As the Japanese cedar pollen count shows large annual fluctuations and increasing trends, more attention should be paid to the usefulness of airborne pollen measurements to predict the number of pollinosis patients.
138 P-10
Creation of Arena for Elderly Welfare in Japanese Agricultural Cooperative
Yuko Kawakami Kameda College of Health Sciences, Japan
1. Introduction Japanese Agricultural Cooperatives have a number of unique historical and cultural characteristics. Historically, they are not industrial associations but regional associations. From the 1970s, Japan’s aging society coupled with young people’s migration to cities saw the number of elderly people rapidly increasing in rural areas. This weakened the Agricultural Cooperatives, community ties and overall vitality in these small communities. The inhabitants of rural areas had various needs and the range of life issues they faced became even more complex in 1980s after the period of high economic growth during the previous decades. 2. Aims of the study The purpose of this study is to present the unique contributions of the Japanese Agricultural Cooperatives to policy regarding elderly welfare in Japanese rural areas. 3. Material and Methods This research used interviews and analysis of primary and secondary literature. Interviewees were staff of the welfare division at agricultural cooperatives during the 2000s in rural Japan. Primary literature included original documents concerning agricultural cooperatives. Secondary literature included government white papers about elderly welfare. 4. Results and Conclusions In the early 1990s, Japanese Agricultural Cooperatives - using home-visit care and day service center etc. - entered the market of elderly care. The enactment of the Long-term Care Insurance System in 1997 led to the principle of welfare pluralism. Many agricultural cooperatives participated in a Long-Term Care Insurance Project. Why? Firstly, to support their elderly ex-farmer members and secondly, to show the significance of the cooperatives to society. As a result, interviewees expected ripple effect to spread across the agricultural cooperatives’ business activities. This study traces the potential and flexibilities of agricultural cooperatives to adapt to the various social situations over this reform of the elderly welfare period.
139 P-11
A Study on the Expectation of Imlant in Koreans
Mi-Sook Cho Choonhae College Dept. of Dental Hygiene, Korea
Objectives: This study has surveyed patient education and counseling, based on the data you want to utilize the expectations on dental prosthetic appliances(denture, bridge) and implants among 307 workers who participated in reservists mobilization training of Hyundai Heavy Industries located in Ulsan. Methods: The collected data was analyzed through IBM SPSS Statistics. v. 19.0 program at the significance level of 0.05. Results: 1. The expectations of prosthetic appliances scored 3.98 and implants scored 3.74. 2. The expectations on implants depending on subjective health status scored 3.74. 3. The expectations on prosthetic appliances and implants were strongly correlated at 0.392. Conclusions: Implants of prosthodontics need for accurate information transfer.
140 P-12
Health Awareness in Elderly Men Living alone: Aimed at four areas of depopulated and aged villages
Kimie Fujikawa Department of Nursing, Faculty of Health Sciences at Nihon Institute of Medical Science, Japan
Purpose: The aim of this study was to clarify an awareness about health of elderly men living alone in depopulated and aged villages. Method: 1. Subjects: 20 elderly men over 75 years old who were living alone. 2. Study period: Between July, 2016 and November, 2017. 3. Study method: A semi-structured interview was conducted. Question items were a health condition: a hospital attendance situation, things subjects were paying attention in daily life and their anxiety for the future. Ethical consideration The study was conducted with the approval of Institutional Review Board (IRB) at Urawa university (No.013). Results: As a result of the cluster analysis, the awareness about the health of elderly men living alone was classified into six clusters below. 1. “Receiving a periodic health checkup over time”. 2. “Taking orally due to hypertension”. 3. “Having a backpain and a gonalgia”. 4. “Having an anxiety about what the future holds”. 5. “Awareness of being healthy”. 6. “Keeping in mind to walk”. Discussion: In consequence of the study about the awareness of the elderly men living alone classfied into six clusters, it was clarified that they were having a health-conscious meal and maintaining a good health. Therefore, it is considered that they concerned about being healthy and tried to spend their life focusing on health-care in order to alleviate their anxiety about what the future holds. Thus, the study suggested that health education including mental care for maintaining or enhancing their current health condition is necessary for them to live alone safely in the familiar area in the future. In addition, this study was conducted with receiving a grant of JSPS KAKENHI Grant Number JP16K12223.
141 P-13
Prevalence of diseases among agricultural workers in rural areas of Japan: Shimane CoHRE study.
Masayuki Yamasaki1,2,3, Shozo Yano3,4, Miwako Takeda3, Tsuyoshi Hamano5, Kunie Kohno3,6, Shimane CoHRE study members*3 and Kuninori Shiwaku2,3 1Faculty of Human Sciences, Shimane University, Japan 2Faculty of Medicine, Shimane University, Japan 3The Center for Community-based Healthcare Research and Education (CoHRE), Shimane University, Japan 4Department of Laboratory Medicine, Faculty of Medicine Shimane University, Japan 5Department of Sports Sociology and Health Sciences, Faculty of Sociology, Kyoto Sangyo University, Japan 6Dept. of Dermatology Faculty of Medicine Faculty of Medicine Shimane University, Japan
Aim: As super aging advances, health promotion depending on the life stages of each person becomes important. In rural areas of Japan, engaging in agriculture can contribute to the health promotion of elderlies and may potentially lead to the extension of healthy life expectancy. To clarify the health status of agricultural workers, the prevalence of each disease was investigated. Methods: Totally, 4,666 consecutive participants aged 40 years or older (1,929 men and 2,737 women) were recruited in health examinations conducted from 2006 to 2014. For analysis, subjects were divided by gender and age group into those who engaged in agriculture and those who did not engage in agriculture. Results and discussion: Engaging in agriculture may have had an effect on the low prevalence of dyslipidemia, a constitutive factor of metabolic syndrome in both men and women between the ages of 40 and 64 years. In elderlies aged 65 years and older, engaging in agriculture may influence the low prevalence of hypertension in men and the control of blood pressure in women. Hypertension and uncontrolled or poorly treated high blood pressure, a strong risk factor for stroke and cardiovascular disease, is a high frequency in Japanese elderlies, and therefore engaging in agriculture may have a significant impact on their prevention and control. Conclusion: In rural areas of Japan, engaging in agriculture may contribute to the control of lipid metabolism in middle-aged people and blood pressure in elderlies.
*Shimane CoHRE study members: Toru Nabika, Koichiro Wada, Minoru Isomura, Kenju Akai, Takafumi Abe, Tsunetaka Kijima, Rie Fukuoka, Kenta Okuyama
142 P-14
Barriers to health education service for the elderly patients with hypertension or diabetes
Yoon Kyung Kim1, Tae-Yoon Hwang2, Min-Ah Nah2, Kyeong-Soo Lee2 and Chang-Yoon Kim2 1Center for hypertension and diabetes registry and education, Gyeongju-si, Korea 2Yeungnam University, College of Medicine, Korea
BACKGROUND & OBJECTIVE: Gyeongju city has been conducting a registry and education program for the elderly patients with hypertension or diabetes since 2012. This program consists of medical expenses support and health education service. As of March 2017, the education completion rate of hypertension and diabetics patients participating in this program is 17.5% and 22.2%, respectively. The purpose of this study was to identify the barriers of the patients enrolled in this program who did not receive health education service. Through this, we intend to find ways to activate education participation. METHODS: A total of 1,041 patients in Gyeongju city, Seonggeon-dong, did not receive educational service. We sampled 105 patients among them using stratified systematic method. Those who stopped medication for 6 months or longer were excluded. The telephone interview survey was performed using structured questionnaire. RESULTS: The frequently answered reasons for not attending educational service were lack of time, lack of education notice, inconvenient transportation to education place etc. The lack of time was a major barrier in the age group of 74 and under, the case of having jobs, and patients with good health status. Inconvenient transportation was a major barrier in the group of poor health status and older age. Most of the subjects did not want education in weekend and evening time, however were willing to attend the education if the education time was available. The lower the age group, the higher the subjects receiving education notice. CONCLUSIONS: Efforts should be made to increase the diversity and accessibility of education places for hypertension and diabetes patients. On-site education in the clinic where the patients meet physician, home health education, develop various ways to announce the health education (include renewing contact information to patients) would be the alternatives to let the patients participate in health education service.
143 P-15
Common Upper Extremity Disorder, Function, and Upper Extremity-related Quality of Life: A Community-based Sample Residing in Rural Areas
Mi-Ji Kim1, Dong Kyu Moon2 and Ki Soo Park1 1Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University School of Medicine, Korea 2Department of Orthopedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Korea
Objective: Upper extremity musculoskeletal disorders (UEMDs) such as rotator cuff tear, epicondylitis, and hand osteoarthritis have a negative impact on quality of life (QOL). In this study, researchers evaluated the prevalence of rotator cuff tear, lateral and medial epicondylitis, and hand osteoarthritis in the dominant side and the impact of these UEMDs on disabilities of the arm, shoulder, and hand (DASH), a tool for assessing upper extremity-related QOL. Methods: In 2013–2015, 987 participants from rural area were administered a questionnaire and underwent physical examinations, laboratory tests, simple radiographic evaluations of bilateral upper extremities, and magnetic resonance imaging studies of bilateral shoulders. Based on data from these participants, researchers evaluated DASH and functional assessment for each region of the dominant side and related UEMDs. Results: The prevalence of epicondylitis, rotator cuff tear, and hand osteoarthritis was 33.7%, 53.4%, and 44.6%, respectively. Univariate regression analysis results between DASH and UEMD or regional functional assessment revealed that only epicondylitis, epicondylitis + rotator cuff tear, epicondylitis + hand osteoarthritis, and epicondylitis + rotator cuff tear + hand osteoarthritis were significantly associated with the DASH score. Multiple regression analysis results between DASH, UEMD, and regional functional assessment showed that only epicondylitis and epicondylitis + rotator cuff tear were associated with DASH score. Conclusion: Epicondylitis significantly affected QOL, while other UEMDs such as hand osteoarthritis and rotator cuff tear had no significant impact. When patients are affected by UEMDs in terms of QOL, there is an increased possibility of the simultaneous presence of other UEMDs.
Key words: Upper extremity, Musculoskeletal disorders, Function, Quality of life
144 P-16
WHO Disability Assessment Schedule 2.0 is related to Upper and Lower Extremity disease Specific Quality of Life: A Community-based Sample Residing in Rural Areas
Jun-Il Yoo1, Ae-Rim Seo2,3, Mi-Ji Kim4, Bokyoung Kim4 and Ki Soo Park4 1Gyeongsang National University Hospital, Center for Farmer’s Safety and Health, Korea 2Gyeongsang National Universityl, Center for Farmer’s Safety and Health, Korea 3Yeungnam University, Korea 4Gyeongsang National Universityl, Center for Farmer’s Safety and Health, Korea
Purpose: We evaluated whether two disease specific quality of life instruments (Disabilities of the Arm, Shoulder and Hand, DASH and Western Ontario & McMaster Universities Osteoarthritis Index, WOMAC) reflect a patient’s perception of general disability using the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) and determined whether disability components are explained by upper and lower extremity HRQOL. Methods: We recruited 421 participants, 50 years or older without stroke, cancer, or history of surgery for musculoskeletal disease, who participated in the Namgaram Cohort. Upper extremity HRQOL was determined with the DASH score and lower extremity HRQOL with the WOMAC; as a measure of disability, we obtained WHODAS 2.0 component. Multiple regression modeling was used to assess the relative contributions made by upper and lower extremity HRQOL to disability. Results: When adjusted for covariates, the DASH total score was correlated with getting around (β=0.217, p<0.001) and social participation (β=0.226, p<0.001), and the WOMAC total score was correlated with getting around (β=0.363, p<0.001), life activation (β=0.363, p<0.001), and social participation (β=0.301, p<0.001). QOL significantly correlated with upper extremity disorders (β = 0.081, p = 0.018) or lower extremity disorders (β = 0.095 p = 0.004). Conclusion: We found that in a community-based population, perceived activity limitation and social participation were associated with upper and lower extremity HRQOL. Since the WHODAS 2.0 does not target a specific disease (as opposed to DASH and WOMAC), it can be used to compare disabilities caused by different diseases.
Keywords: Disability, Lower Extremity, Quality of Life, Upper Extremity, WHO
145 P-17
Head, upper trunk, and lower trunk axial rotation angles in young baseball players with a history of throwing-related pain
Masashi Kawabata1, Toru Miyata1, Hiroaki Tatsuki1, Yohei Kusaba2, Yuichi Kashiwazaki2, Shigeru Ishii3 and Seigo Takano3 1Rehabilitation Center, Sagamihara Kyodo Hospital, Japan 2Department of Orthopedics, Sagamihara Kyodo Hospital, Japan 3Sagamihara Kyodo Hospital, Japan
Purpose: This study aimed to examine the head, upper trunk, and lower trunk axial rotation angles in young baseball players with and without a history of throwing-related pain. Methods: Sixty-one young baseball players aged 9–12 years participated. They were divided into two groups: 18 men with >1-week history of persistent pain in the shoulder or elbow (injury group) and 43 healthy men (control group). The head, upper trunk, and lower trunk axial rotation angles were measured during those active motions of the dominant (D) and non-dominant (ND) upper limbs directions in a fixed stationary position. Results: The axial rotation angles of the head and upper trunk in D and ND directions were significantly lower in the injury group than in the control group, and those in the lower trunk were not significantly greater in either direction in the injury group than in the control group. Regarding rotational directions, the angles of the upper trunk were greater in the ND direction than in the D direction in the control group, whereas those in the lower trunk were greater in the D direction than in the ND direction in both groups. Discussion: These findings suggested that the axial rotational function decreased in the head and upper trunk in the injury group. Thus, the superiority of the rotational direction and angle in the head and trunk suggests that evaluating them is crucial. However, further examination of the causal relationships is needed.
146 P-18
Relationships between limbs reach tests and range of motion in young baseball players with a history of throwing-related pain
Toru Miyata1, Masashi Kawabata1, Hiroaki Tatsuki1, Yohei Kusaba2, Yuichi Kashiwazaki2, Shigeru Ishii3 and Seigo Takano3 1Rehabilitation Center, Sagamihara Kyodo Hospital, Japan 2Department of Orthopedics, Sagamihara Kyodo Hospital, Japan 3Sagamihara Kyodo Hospital, Japan
PURPOSE: We investigated relationships between limbs reach tests and range of motion in young baseball players with a history of throwing-related pain. METHODS: Sixty-one baseball players aged 9–12 years were divided into two groups: 18 men with >1-week history of persistent pain in the shoulder or elbow (injury group) and 43 healthy men (control group). They performed arm reach test to measure the maximum distance between the dominant middle finger and the non-dominant second toe in a position similar to the follow-through phase. In a position similar to the early cocking phase, they performed leg reach test to measure the maximum distance between the non- dominant toe and dominant medial heel. These reach tests were normalized by the length of their arm and leg, respectively. We measured the range of motion (maximum extension and rotation of the trunk, shoulder, and hip) and used multiple regression analysis to determine the effect of these factors on the limbs reach tests. RESULT: The distances of arm reach test but not leg reach test were significantly lower in the injury group than in the control group (p < 0.05). Arm reach test was significantly affected by the axial rotation angles of the head and upper trunk in the dominant direction (R = 0.27, p < 0.01). DISSCUSSION: These findings suggested that arm reach test was related to throwing- related pain, and the axial rotation angles of trunk influenced this test. Such evaluations are crucial in young baseball players.
147 P-19
A single rural community hospital experience of simultaneous laparoscopic cystectomy and laparoscopic nephroureterectomy with umbilical reduced port surgery outcome
Takehiko Okamura, Ryosuke Chaya, Takashi Nagai, Yoshinobu Moritoki, Daichi Kobayashi and Hidetoshi Akita Anjo Kosei Hospital, Japan
Background and Objective: In recent years, although reduced port surgeries (RPS) have been reported for many urological diseases, there have been no reports regarding simultaneous laparoscopic cystectomy and unilateral or bilateral nephroureterectomy with umbilical RPS. Therefore, the aim of this study was to evaluate outcomes and complications of simultaneous laparoscopic cystectomy and unilateral or bilateral nephroureterectomy with umbilical RPS in a single rural community hospital. Materials and methods: We performed a preliminary case series of 4 patients with synchronous upper urinary tract (UUT) tumor and invasive bladder cancer who underwent simultaneous laparoscopic cystectomy and unilateral or bilateral nephroureterectomy with umbilical RPS between 2014 and 2017 at our hospital. Demographic data, pathologic features, the surgical technique, and outcomes were retrospectively analyzed. Result: All 4 patients were men whose median age was 79 years (range 65-85 years) and median body mass index was 24.2 kg/m2 (range 21.5-27.3 kg/m2). The laparoscopic approach was technically successful in all 4 patients without the need for open conversion. The median total operative time was 434 minutes (range 372-481 minutes). The median estimated blood loss was 773 ml (range 153-923 ml), median interval to resuming oral intake was 2 days (range 1-7 days), and median hospital stay was 16 days (range 13-20 days). Conclusions: The reduced port approach is technically feasible in terms of many outcome measures, with significant cosmetic advantages. This method can be performed safely and recommended as a viable option for patients with concomitant UUT and bladder cancer.
148 P-20
Statistical analysis of Ki-67 labeling index in breast cancer as prediction of prognosis
Maiko Kawai1, Akio Kazama2, Ichiro Maeda2, Tomohiro Kimura3, Daisuke Fujihira3, Hisataka Onda1, Shigeru Ishii4 and Seigo Takano5 1Clinical Laboratory, Japan 2Department of Pathology, Japan 3Department of Surgery, Japan 4Department of Medical Technology, Japan 5Director of Hospital, Japan
Introduction: St. Gallen consensus meeting in 2011 advocate subtype classification of breast cancer, based on immunohistochemical staining of ER, PgR, HER-2, and Ki-67. Ki- 67 has an important role for cell division, and we examined it in breast cancer as predicting prognostic parameter. Aims of the study: Ki-67 protein in the nucleus is expressed in certain phases of the cell cycle (G1, S, G2, M), but is absent in resting cells (G0), thus known as an important marker for the cell growth function in neoplasms. We examined the Ki-67 labeling index (Ki-67 LI) of breast cancer, and investigated the relevance between the Ki-67 LI and other pathological factors. Material and methods: A total of 163 cases of breast cancer was measured, the all of cases was resected in our hospital during January 2015 to December 2017. The average age of 163 cases was 62.6 year-old (30 to 86 year-old). We classified the subject cases by pathological factors (tumor size, vascular invasion, lymph node metastasis, nuclear grade, ER, PgR, HER-2 expression), and found the average value of the Ki-67 LI, and examined the statistically significant difference. Results: There were no significant difference between Ki-67 LI and vascular invasion or lymph node metastasis, but in tumor size and ER and PgR expression. Conclusion: In St. Gallen risk classification, the tumor size and ER and PgR expression are regarded as prognostic factor. Our results shows the Ki-67 LI is considered to be a useful parameter for predicting prognosis for breast cancer.
149 P-21
The present conditions and the future prospects of the palliative radiotherapy in our hospital
Shunji Okae Anjo Kosei hospital, Japan
Our hospital is placed with a core hospital of the cancer medical treatment in the area as the cancer medical treatment cooperation base hospital which Japanese goverment appoints. It is surgical operation, chemotherapy and radiotherapy that is related to cancer medical treatment. There are several requests of the radiotherapy from other clinical departments of in our hospital or the outsides medical institutions, and there are multiple request purposes, and the request of the palliative radiotherapy is pointed as important one. The main treatment regimen has the reduction of the pain, dyspnea and passage disorder at the time of eating caused by the cancer. It is the radiotherapy of the sharp pain reduction purpose due to the bone metastasis that there is particularly much. A method to perform 30 Gy with division into ten to a lesion was common, but 20 Gy came to be reported division into five or 8 Gy recently when law was as effective once and came to begin to adopt even our hospital now. In addition, the examples which enforced the second radiotherapy to the part that gave radiotherapy increased once. We would like to report the contents and the risk of these cases. And to report the abscopal effect becoming the topic recently and would like to consider the possibility that palliative treatment is connected for the prolongation of human life.
150 P-22
Spatial distribution and clusters of small area cancer incidence in Chungnam province, South Korea
Jee-Hyeon Choi and Hae-Sung Nam Graduate School of Chungnam National University, Department of Public Health, Korea
Background: Mapping of cancer incidence may be useful to search a hypothesis on risk factors associated with the cancer. We would like to describe a spatial variation in small area cancer incidence and explore cancer clusters in Chungnam province, South Korea. Method: The cancer cases that occurred in each small area (eup, myeon, or dong) during 2007 to 2011 were identified from the Chungnam Cancer Registry database. In this database, we changed each legal name of small area into its corresponding administrative name that was presented in the map file of Statistical Geographic Information Services, Statistics Korea. The indirect standardized incidence ratio (SIR) for 5 years was calculated as follows: SIR = the observed number of cases for 5 years / the expected number of cases for 5 years. To calculate the expected number of cases, we used the number of population (by age group with 5 year interval) of each small area and the corresponding age group specific incidence rates of the standard population, South Korean population in 2012. Using the software R, we matched the calculated with its corresponding small area of the map file. This study used spatial correlation and Kulldorff-Nagawala’s Scan statistic with Moran’s I for mapping of occurrence rate and spatial analysis using SIR. Result: Top region was Bongmyeong-dong, Cheonan-si(SIR 1.50). Based on for all cancers, clusters were found in Geumsan-gun and Nonsan-gun; for stomach cancer in Geumsan-gun; for colorectal cancer in Cheonan-si; for liver cancer in Geumsan-gun; for lung cancer in Boryeong-si; for breast cancer in Cheonan-si and Asan-si; for cervical cancer in Yeongi-gun Conclusion: Using the software R, we could visualize the geographic distribution of small area cancer incidence in Chungcheongnam-do, South Korea. Further epidemiological studies seems to be needed to explore the contributing factors for the clusters.
151 P-23
Active lifestyle related to well-being of elderly residents in a healthy city aiming at successful aging
Nobuhito Ishikawa1, Akiko Hoshino2, Miho Shizawa2, Kanae Usui2, Mai Ogura1, Michiko Komata1 and Toshiki Katsura1 1Preventive Nursing, Department of Human Health Sciences, Graduate school of Medicine, Kyoto University, Japan 2Public Health Nursing, Graduate School of Nursing for Health Care, Kyoto Prefectural University of medicine, Japan
Introduction: In super-aging period elderly Japanese residents need to have active lifestyles aiming at successful aging. In particular it’s important for “old-old” aged 75 years and over to keep their well-being better through lifetime. Aims: The purpose of this study is to verify the active lifestyle factors related to well- being of elderly residents aiming at successful aging, and to compare lifestyle factors between “young-old” aged 65-74 years and “old-old”. Methods: Subjects were randomly selected from all elderly residents in A City, Kyoto, Japan. Questionnaires were distributed to 2,473 elderlies randomly selected in Des. 2015. 1,419 elderlies were analyzed in this study. Active lifestyles related to well-being were compare between “young-old” and “old-old”. Ethical approval for this study was obtained. Results: 724 (73.6%) of “young-old” and 309 (70.5%) in “old-old” had good well-being. Active lifestyles related to better well-being were as follows. In “old-old” elderlies active lifestyles were taking health checkups, caring about salinity, eating vegetables, doing exercise, not feeling stressed, taking enough rest, going out three a month or more, joining district events, having relationship other than work and having fun or purpose. In “young- old” elderlies in addition to those of “old-old” residents taking regularly meals, eating breakfast at every morning, eating dinner two hours before bedtime, eating dinner at every night, eating seaweed or mushrooms at least once a week and no smoking were active lifestyle. Conclusions: Active lifestyles are considered be important to keep well-being better in elderly residents. This study was collaborated with Kizugawa City.
152 P-24
Social appearance (sekentei) and cognitive decline among community-dwelling older adults in rural Japan
Hiroshi Murayama1, Yugo Shobugawa2, Takeo Fujiwara3 and Shigeru Inoue4 1Institute of Gerontology, The University of Tokyo, Japan 2Division of International Health (Public Health), Niigata University, Japan 3Department of Global Health Promotion, Tokyo Medical and Dental University (TMDU), Japan 4Department of Preventive Medicine and Public Health, Tokyo Medical University, Japan
Introduction: The concept of social appearance (sekentei in Japanese) is defined as a sensitivity about one’s reputation. It reflects Japanese behavioral principles and involves pressure to conform to social norms, particularly among people living in rural areas. Previous studies have reported that social appearance is associated with attitudes toward the use of care services. However, evidence is sparse on the relationship between level of social appearance and health outcomes such as cognitive function. Aim of the study: To explore the association between social appearance and cognitive decline (CD) among community-dwelling older adults in a rural area in Japan. Material and Methods: Data were drawn from the NEIGE Study, a prospective cohort study of community-dwelling individuals aged 65–84 years living in Tokamachi City, Niigata Prefecture, Japan. The baseline survey was conducted in 2017 and included 527 independent older people (249 men and 278 women; average age 73.6 years [standard deviation: 5.6]). Social appearance was measured using the 12-item Sekentei Scale (score range: 12–60). Cognitive function was assessed using the Mini-Mental State Examination. A score of ≤26 was regarded as indicating CD. Results: About one-third of participants were categorized as having CD. We divided Sekentei scores into sextiles and conducted a logistic regression analysis. The results showed that, after adjusting for covariates such as sociodemographics, health behaviors, and health conditions, the highest and lowest sextiles were associated with CD (reference: moderate Sekentei score category). This result was consistent when quintiles instead of sextiles were used in the analysis. Conclusions: Both high-level and low-level awareness of others or society might be strongly associated with CD and dementia incidence among older people in rural areas. This suggests that a moderate-level social appearance is more beneficial for cognitive health. Future studies should investigate the causality of this association.
153 P-25
Relationship between Frailty and applied activities of daily in elderly people living in low-rural rural areas. ~Focusing on social behavior in indoor and outdoor~
Saki Ikedo1, Yuka Matsumoto2, Ryosuke Takagi3 and Wakaya Fujii4 1Department of Rehabilitation Tohno Kosei Hospital, Japan 2Department of Rehabilitation Bisai Memorial Hospital, Japan 3Department of Rehabilitation Bisyu Hospital, Japan 4Department of Rehabilitation, Major in Occupational Therapy, Gifu Junior college of Health Science, Japan
Purpose: In this research, from the preventive viewpoint of frailty of elderly people living in lowland rural areas, it is to clarify the relationship between frailty and applied activities of daily living. Method: First of all, 184 subjects were classified into 3 groups of frailty group, pre-frailty group and non-frailty group according to J-CHS (Fried). Subsequently, we carried out the analysis of variance (kruskal-wallis) on the results of the sub-items of the Frenchay Activities Index (FAI) and then carried out the multiple comparison test (steel-dwass). Sub-items are preparing main meals (PM), washing up (WU), washing clothes (WC), light housework (LH), heavy housework (HH), local shopping (LS), social outings, (SO) walking outdoors (WO), pursuing active interest in hobby (PAH), driving a car (DC), outings/car rides (OCR), gardening (GD), household and/or car maintenance (HCM), reading books, (RB) gainful work (GW). Then, the area under the curve (AUC), sensitivity, specificity, and cutoff value were calculated by ROC analysis. Prior to this research, we have obtained approval from the ethics review board of Gifu Junior college of Health Science (H29-05), and the subjects have been approved after written and oral explanation. Result: Among the subjects, there were frailty group(9), pre-frailty group(61), and non- frailty group(114). In the analysis of variance, significance was recognized in all sub- items. In the multiple comparison, significant differences were observed among all items between non-frailty group and frailty group. Between non-frailty group and pre-frailty group, there was a significant difference between items other than WC and DC. Between the pre-frailty group and the frailty group, significant differences were found in items other than OCR, GD and HCM. As a result of ROC analysis, AUC 0.9922, p<0.001, FPF0.0439, TPF1.000, cutoff value26/27 in case of frailty/non-frailty. In the case of pre- frailty/non-frailty, AUC 0.7953, p<0.001, FPF0.3333, TPF0.8525, cutoff value36/37. Conclusion: From the above, it was thought that implementation of various applied activities of daily living is related to frailty’s prevention. Moreover, it became clear that FAI is useful as an indicator of the determination of frailty.
154 P-26
Relationship between Frailty and physical and psychosocial factors in elderly people living in lowlands rural areas. -Examination of factors by discriminant analysis-
Wakaya Fujii1, Saki Ikedo2, Yuka Matsumoto3, Ryosuke Takagi4 and Hirofumi Hirowatari5 1Department of Rehabilitation, Major in Occupational Therapy, Gifu Junior college of Health Science, Japan 2Department of Rehabilitation Tohno Kosei Hospital.O.T.R, Japan 3Department of Rehabilitation Bisai Memorial Hospital.O.T.R, Japan 4Department of Rehabilitation Bisyu Hospital.R.P.T, Japan 5Department of Rehabilitation, Major in Occupational Therapy, Gifu Junior college of Health Science, Japan
Purpose: In frailty, not only individual behavioral habits but also local environmental, physical functions, psychosocial factors are complicatedly related. Therefore, the purpose of this research is to clarify the characteristics of Frailty from multiple physical functions and psychosocial data of elderly people living in low-rural rural areas. Method: First of all, 184 subjects were classified into 3 groups of frailty group, pre-frailty group and non-Frailty group according to J-CHS (Fried). Subsequently, we conducted an Analysis of variance (Kruskal-Wallis test, Multiple comparison test:Steel-Dwass) on physical and psychosocial items. The physical function item was used for analysis in Grip strength (kg:GS), Walking speed (m/sec:WS), Body Mass Index (BMI). Psychosocial items used for analysis in Frenchay activities index (FAI), Kihon-checklist (CL), Exercise habit scale (ES), and Number of people living together (NPL). Then, discriminant analysis was carried out using 3 groups as the objective variables and items for which a significance was observed in the Analysis of variance as the explanatory variable. Prior to this research, we have obtained approval from the ethics review board of Gifu Junior college of Health Science (H29-05), and the subjects have been approved after written and oral explanation. Result: Among the subjects, there were frailty group (9 people), pre-frailty group (61 people), and non-frailty group (114 people). As a result of analysis of variance, significance was recognized in WS (p=0.0095), BMI (p=0.0081), FAI (p<0.001), CL (p<0.001), ES (p<0.001). Significance was not recognized in the item of GS and NPL. Results of discriminant analysis, 2 significant functions was observed. The standardized canonical discriminant function coefficients of function 1 were ES (0.6211), FAI (0.5407), WS (- 0.1940), CL (- 0.3341). For function 2, it was FAI (0.7880), WS (0.3718), CL (-0.3341), ES (- 0.5851). Discriminant predictive values were frailty (77.8%), pre-frailty (59.0%) and non- frailty (94.7%). The center of gravity (mean of group discriminant function) of each group showed the highest value in the function 1 group in the non-frailty (0.8419) and the function 2 in the pre-frailty (0.3233). Conclusion: From the above,in particular ES and FAI became influential indicators of frailty, suggesting the relationship with exercise habits and applied activities of daily living.
155 P-27
Association between mobile technology use and emotional/behavioral adjustment in elementary school
Rikuya Hosokawa1 and Toshiki Katsura2 1Nagoya City University, Japan 2Kyoto University, Japan
Introduction: Children’s time spent using digital devices is increasing rapidly with the development of new portable and instantly accessible technology, including smartphones and digital tablets. With the dramatically rapid development of media games, learning packages, and educational applications for young children, opportunities for using mobile devices have been growing, children’s usage time has become increasingly longer, and child target users of mobile devices are becoming younger. Although prior studies examined the effects of traditional media on children’s development, limited evidence exists on the impact of mobile device use. Aims of the study: This study aimed to clarify the link between mobile device use and childhood emotional/behavioral adjustment. Material and Methods: The sample included 716 8-year-olds in third grade at Japan’s elementary schools. Parents completed a self-report questionnaire regarding children’s use of mobile devices and the Strengths and Difficulties Questionnaire to indicate emotional/behavioral problems. We performed inverse probability of treatment weighted (IPTW) logistic regression to compute odds ratios (OR) for emotional/behavioral problems according to mobile device use. Results: The values for IPTW analysis were computed based on sociodemographics and child characteristics. Among the participants were 85 (11.9%) regular users (90 minutes or more on a typical day) and 631 (88.1%) non-regular users (under 90 minutes on a typical day). Relative to non-regular use, regular use was significantly linked to conduct problems (IPTW-OR: 2.00 95% CI: [1.05–3.82], p < .05), emotional symptoms (IPTW-OR: 2.19 95% CI: [1.08–4.41], p < .05), and peer problems (IPTW-OR: 2.14, 95% CI: [1.23– 3.75], p < .01). Conclusions: Therefore, routine and frequent use of mobile devices appear to be associated with childhood emotional/behavioral problems. Excessive use of mobile devices might interfere with children’s development of social adjustment. Our findings suggest that preventing excessive use of mobile devices may reduce the likelihood of childhood emotional/behavioral problems.
156 P-28
A case report of very late recurrence of epithelial ovarian cancer at an extremely rare region: the Canal of Nuck after 26 years of disease free interval
Ikuno Yamauchi Tsuchiura Kyodo General Hospital, Japan
The morbidity rate of ovarian cancer is increasing in Japan. It is the 7th most common cause of cancer death in Japan, accounting for 3% of all cancers in female. In epithelial ovarian cancer, it is well known that chemotherapy response rate is high but recurrent rate is also high. Approximately 70% of patients diagnosed with ovarian cancer will have a recurrence. The usual recurrent patterns are local invasion and lymphogenous and hematogenous spread. The Canal of Nuck, the female homologue of hydrocele of spermatic cord, has never been reported as a recurrence region of ovarian cancer. Almost 55% of recurrence of ovarian cancer occurs within 2 years, and more than 70% of recurrence occurs within 5 years. 26 years of disease free intervalis extremely long for ovarian cancer. Here we present the case of a 76-year-old female with carcinoma at Canal of Nuck as a possible pattern of recurrence of ovarian cancer. We encountered a 76-year- old woman, gravid 2, Para 2, with a 5-year history of cystic swelling at the right groin. She had experienced complete surgery and adjuvant chemotherapy of paclitaxel and carboplatin for stageIIB ovarian cancer at the age of 50. She exhibited disease-free survival for 5 years, at which time cancer-follow-up finished. Radiographic tests revealed the cyst with solid compartment at the Canal of Nuck. The tumor was suggested as a carcinoma so we decided tumorectomy. Pathological tests revealed that the tumor was recurrence of ovarian cancer. She underwent postoperative chemotherapy of paclitaxel and carboplatin for 6 monthe and got disease free. We have experienced recurrence of ovarian cancer after long time at an unexpected region. Whereas the majority of ovarian cancers are recurred within 5 years, this case suggest that a physical examination after 5 years is important.
157 P-29
Difficulty of Responce to Mental Patients Receiving Hemodialysis Therapy in Dialysis- Health Care- Workers
Ayako Fujita Nihon Instiute of Medical Science, Japan
Purpose: As of the end of 2016, number of maintenance-hemodialysis patients in Japan was about 330,000. There is a possible cause responsible for difficulty in continuance of the maintenance-dialysis and self-management of mental patients due to their lack of correct understanding about the dialysis for chronic renal failure caused by their cognitive distortions. The study was conducted to clarify what difficulty dialysis health-care workers felt with the mental patients. Method: Self-administered questionnaire was done with 19 health-care workers in hemodialysis facilities in a mental hospital. The question items were attributes of the workers: difficulty they felt and ways to cope with problems during dialysis, practical situations of observation and management specific to mental illness. Besides, we gained the approval of research ethics committee at Nihon Institute of Medical Science. Results: As a result of qualitative and inductive analysis, four categories as “danger due to removing needles by patients themselves”, “nontreatment decision”, “difficulty in life- management” and “cessasion of dialysis” were extracted. The workers realized that the care for removal of the needle by patients during dialysis was important because it led to threat to patient’s life. Therefore, they emphasized patient safety and observed patient’s behavior, responded quickly when they found patient’s threat during dialysis. Discussion: The workers thought mental patient’s lack of conciousness of disease led to be the reason why the patients caused dangerous behaviors during dialysis. However, we considered that the patients who had difficulty in self-manegement caused them because they had a physical hard experience via dialysis such as a reduction in blood-pressure due to decrease of water removal quantity at the time of dialysis caused by weight gain. Consequently, it is suggested that focusing on self-management of the patients at first and having an educational involvement that can help the workers to do the dialysis safely are necessary.
158 P-30
The combination of Berg Balance Scale and Moss Attention Rating Scale for assessment of walking independence in acute ischemic stroke
Keisuke Inoue1, Yoshiyuki Numasawa2, Satoshi Sutou1, Masaki Hakomori1, Kazunori Toyoda1 and Hiroyuki Tomimitsu1 1JA Toride Medical Center, Japan 2Tokyo medical and dental university, Japan
Purpose: There is no report to assess the walking independence at the start of walking in patients with acute ischemic stroke. This study is aimed to evaluate the usefulness of the combination of Berg Balance Scale(BBS) and Moss Attention Rating Scale(MARS) for assessment of the walking independence at the start of walking after ischemic stroke. Methods: We retrospectively enrolled 85 patients with acute ischemic stroke (men/ female=58/27, age=76±13 years-old) and classified these patients into independent walking group (Functional Ambulation Categories/ FAC:4) and non-independent walking group (FAC:2-3). Age, NIH Stroke Scale, modified Rankin Scale, BBS, MARS, and the duration from onset of stroke to evaluation of walking independence were investigated. Logistic regression analysis was applied to clarify the factors associated with walking independence, and the cut-off values were determined by the receiver operating characteristic curve. Likelihood ratio was calculated based on contingency tables of walking independence and the cut-off values. Moreover, we investigated the validity of assessment with the factors. Results: Sixty independent and 25 non-independent patients were enrolled. The patients of independent group did not fall in the hospital. The duration from onset to the evaluation was 6.9 ±3.0 (mean±1SD) days. The identified significant factors associated with walking independence were BBS and MARS total score. The negative likelihood ratios were 0.3 with BBS alone, but 0.0 with the combination of BBS and MARS total score. Conclusion: To evaluate walking independence in acute phase of stroke, the combination of BBS and MARS could show lower negative likelihood ratio than BBS alone. This method could make us know the risk of fall in the patients more objectively and more sensitively.
159 P-31
Examination of the effect of intervention of image training on patients with chronic stroke
Takahiro Takenaka1 and Yoshinori Kimigaki2 1Heisei College of Health Sciences, Japan 2Specific medical corporation hakuaikai hakuaikai hospital, Japan
Introduction: It is said that there are 1,179,000 people suffering from stroke throughout Japan, and many patients live their lives with paralysis of physical function and limited activity. In this study, we examined the effect of 2 months of intervention using image training using “image of familiar movement that I would like to do again” on the improvement of paralysis in patients with chronic stage stroke living in rural areas. Subjects: Twelve stroke patients in chronic phase (mean disease duration 1436 ± 954 days) Method: After measuring the degree of paralysis (Brs), grip strength, subjective ease of mobility (VAS), muscle tone (MAS), he interviewed “Interaction that I want to do once again” and the spinal cord Measure excitability of anterior horn cells with F wave. After that I did image training at home at home for 5 minutes every day. And after 2 months we reevaluated. Result: There was no improvement in objective evaluation items such as Brs, MAS and grip strength, but a significant improvement was seen in subjective evaluation VAS. The F wave did not change at rest at the time of the initial stage and at the time of the image, but after 2 months it was significantly excitable at the time of the image rather than at rest. Discussion: Even if the period has passed since the onset of disease, there was an improvement in mobility by exercise image training, and certain effects were observed in which the excitability of the anterior horn cells of the spinal cord increased by imaging.
160 Advertisement Acknowledgements
Astellas Pharma Inc.
Baxter
Bayer Yakuhin, Ltd.
Eli Lilly Japan K.K.
JOHNSON&JOHNSON K.K.
Novo Nordisk Pharma Ltd.
Pfizer Japan Inc.
TERUMO CORPORATION
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