Japan's population is aging faster than that of any other nation on earth.1 This fact reflects a nearly 50% increase in life expectancy and an even larger drop in birth rate since the end of World War II.2,3 Reports from the Japanese government indicate that by the year 2000 Japan will have the largest proportion of citizens aged 65 years and older in the world.4 Currently, only 9.8% of Japan's population of 119.5 million is aged 65 or older; by the year 2020 this figure will approach 25%, if the present rate of increase continues. This article reviews the social context from which this circumstance has emerged and describes how one community is facing this situation today.
The Social Context
A rapid demographic shift has resulted from radical changes in lifestyle during the postwar era. The average number of children per family in 1947 was five; now the number is about 1.77. The country has enjoyed increasing prosperity with the growth of Japanese industry in size, quality, and international scope. The rising affluence of individual workers has, in turn, raised the expectations of succeeding generations. A literacy rate of 99.3% has been achieved. Ninety- four percent of all schoolchildren move on to high school, and 39% attend college or junior college. These statistics imply great family expense, as financial aid is less prevalent than in the United States and education costs at the private, higher education institutions, which most students attend, rival those of America's most elite schools.5
Life expectancy has risen from 50.06 years for men and 53.96 years for women in 1947 to 74.22 and 79.66 years, respectively, the longest life expectancies in the world.1 It has been the traditional practice in Japan for the eldest son to care for his parents, to live with them and work in the family enterprise.6-7·8 The wife of the eldest son has been expected to perform all home management activities, including care of her in-laws. Japan is a culture in which such duty and obligation are the cornerstones of tradition. In the family that has only daughters, the husband of one (who is not himself an eldest son) may be legally adopted and take on the family name and the filial responsibilities of eldest son.
To accommodate younger workers many companies enforce a mandatory retirement age of 55 years. However, most pension plan annuities do not begin until the individual reaches age 65. Many workers seek lesser jobs to supplement life savings during the intervening decade. Pensions in Japan average $450 per month, which is 43% of the average wage. Benefits do not extend to part-time workers, the category under which most women workers fall, and widows are generally expected to be supported by their families rather than by their husbands' companies or the Japanese government. At present there are seven workers per one old-age pensioner in Japan. Assuming that current trends prevail, in 35 years this ratio will be less than two to one.4
The suicide rate in Japan, according to 1984 World Health Organization data, stands at 17.4 per 100,000.9 The highest rate always has been among the elderly.10 Now the greatest increase in incidence is occurring among middleaged men. It is hypothesized that the cause of this trend is their growing apprehension as they face retirement. Although suicide always has been more legitimate in Japanese culture than in Western culture, it is still a troubling occurrence. The growing rate among middle-aged men is regarded by Japanese social scientists as symptomatic of Japan's not yet having come to terms with its increased life expectancy.1
The traditional form of caring for the elderly (ie, care by a son and daughter. in-law) has become more difficult in recent years. Industrial and corporate development has been greatest in Tokyo and other major cities where the best job opportunities and the best schools for workers' children are found. With migration to the cities, families are most often forced to live in small apartments, which do not afford space for aging parents even if they are willing to move.11,12
Japan has, in recent decades, prided itself on achieving a middle-class comprising 90% of its population. However, in recent years citizens have felt less prosperous.13 Many families now report the need for the wife to work for pay outside the home to meet living expenses and to educate the children. This radical change in the role of women since the urban migration began is slow to be officially recognized. In fact, the traditional homemaking role accounts for only 32% of Japanese females 15 years of age and over.14 Official figures do not reflect the work of women in family enterprises, such as farming or shopkeeping. Several recent surveys report that families are increasingly dependent on the wives' earnings to maintain their middle-class status.15,16
A final area to examine concerns health care for the elderly. Care for the elderly in terms of housing facilities or nursing homes is not highly developed. This lack of development reflects that until now families have handled this responsibility quite effectively. A current problem receiving considerable attention is the government's efforts to reduce the nation's medical costs. By the year 2000 it is anticipated that medical expenditures will be 3.51 times current levels largely because of the growth in the number of elderly. Over half of the national health insurance expenditures are expected to be made on behalf of elderly persons by the year 1999; this is already the case in 61 municipalities. It is anticipated that by the year 2000, 55% of workers' disposable income will be taken as taxes to pay for social welfare programs. At the same time, the amount of individual savings, the backbone of the Japanese economy, will shrink as families spend more on individual medical costs and taxes. Currently, the government is advising a 10% decrease in the number of physicians and a 20% decrease in the number of dentists licensed each year over the next ten years to prevent a surplus.17"19 Yet the health needs of the population continue to increase dramatically as the proportion of elderly increases.
Nursing leaders indicate that the nursing profession is already experiencing a shortage, although it is less acute now than it was five years ago. There are 368 diploma schools and 36 junior college educational programs in nursing. Although professional nursing education and baccalaureate entry are goals of the Japan Nursing Association (JNA), there are only 11 baccalaureate and two master's degree programs in the country, which account for 1% of the nursing graduates each year. About half of the individuals currently being trained to provide nursing care are in nursing assistant programs, which consist of two or three years of vocational training following the completion of junior high school. Many of the 30,000 individuals who pass the registered nurse licensure examination each year do not enter the work force or leave shortly after entry, as retirement at the time of marriage or the first pregnancy is still commonplace among women workers.20-22
The net effect of these circumstances is a shortage of those able to give conceptually-based professional care. This situation can be expected to worsen as the pool of young people available to enter professions shrinks and the proportion of elderly requiring intensified efforts increases. There is not yet a tradition for adults to return to school in midlife to begin or change careers.
Several trends become clear after considering these interrelated social changes. The proportion of elderly in Japan is growing rapidly while the number of workers to support them is decreasing. People are living longer, perhaps several decades after mandatory retirement, and there is often a gap of up to ten years between retirement and the beginning of pension annuities. It will become increasingly difficult for families to care for their elderly parents, as they will have less disposable income and living space, and because women will increasingly work outside the home out of economic necessity. There will be fewer children per family to share responsibility for aged parents. The medical benefits provided its citizenry by the Japanese government may be expected to decrease and at the same time to become more costly. Social structures for care of an aged population are not yet in place. There is little time for Japan to devise and implement strategies to meet the challenge of a rapidly aging society, and there are no role models among other nations. The United States faces each of these problems in the decades ahead, though perhaps with different degrees of acuteness.
Efforts of a Rural Health Center
At least one local community health service has responded to the reality of 25% of its local population being 65 or older.
Shikoku Island, on the Inland Sea, is the smallest of Japan's four main islands. It is moderate in climate as it is warmed by the Japan current on its Pacific side. In summer it receives even more rainfall than most of Japan, which is in Asia's monsoon region.23 Shikoku Island is primarily rural, and rice and citrus fruits are the main crops.
There are four prefectures in Shikoku, of which Kochi Prefecture, curving around the Pacific side, is the largest. It is from Kochi City, the prefectura! capital, that all government services, including the ten regional community health centers within the prefecture, and their local centers, are directed.
Arrangements were made for the authors, accompanied by the prefectural director of public health nursing, to visit the prefecture's most rural local community health center. The center is located in the mountains, one hour northwest of Kochi City by car. In this community of 131 square kilometers reside 6,300 people, of whom one fourth are 65 or older. This is the second highest proportion of elderly among all communities in Japan . It is a measure of the community's concern that the town government is urging young women to have more than the usual two children each, with the hope that larger numbers will grow up and remain in the area.
This small community has two hospitals, two clinics, and two dental clinics. Trauma cases are transferred to Kochi City, but even in Kochi City the prefectura! director of public health nursing indicated that there are no intensive or coronary care facilities. The only recourse is to transfer individuals to Tokyo or another large city on the island of Honshu.
In cooperation with the town government, the local community health center has embarked on several plans to aid the community's elderly. Three of these plans are the health education and screening program, the nutritional counseling program, and the system of nurse intervention.
Prior to the adoption of the automobile by the general population, this village was considered far from the sea. In the mountains, much of the food had to be salted for storage. In earlier epidemiological studies, high death rates due to cerebrovascular accidents were observed. The food habits, which developed out of necessity in former times, remain as food preferences today. Therefore, in 1978 this local health center developed and implemented a health education program that emphasized screening for cardiovascular disease as well as cancers of the stomach, the uterus, and the breast.
There are only two public health nurses stationed in this local clinic. To help recruit citizens to participate in the program and to assist in the physical examinations, health volunteers had to be selected from within the community. The establishment of this program and the development of a corps of volunteers were tasks undertaken by the clinic, which had no prior experience in this type of effort.
The program is all the more impressive because organized volunteerism is a relatively recent development in Japan.24,25 The director of this health development committee program is a volunteer who studied health education for one year. The volunteer workers in her program, 346 of whom are now assigned among the town's 32 sections, attended monthly classes for one year; the conclusion of the education program was marked by a graduation ceremony.
The volunteers visit townspeople to urge them to attend the screening days at this or other local or regional centers. If they note health problems during these home visits, the volunteers can report them either to the town hall or directly to the public health nurses, who then follow up with a home visit. The volunteers focus particularly on residents aged 53 or above. If the residents decline the offer of health screening, the volunteers make one or two follow-up visits to encourage participation. If the individuals agree to participate, then the volunteers schedule their visits to screening days at the clinic.
This procedure may strike Westerners as extremely persistent, even to the point of invading personal privacy. But the notions of privacy and community aie, particularly in rural Japan, very different from those observed in the West. In many aspects of health care, compliance is markedly high. Self-refer- k rais to the public health system are far more frequent than referrals by hospital staff.
The basic examination, focusing on cardiovascular status, is comprised of serum albumin, glucose and liver function tests, urine analysis, electrocardiogram, blood pressure screening, and examination of eye grounds and glaucoma screening. Although the cost of the examination is 4,500 yen, or about $28, the town absorbs this expense. Other screening is available beyond the basic physical examination (see Table).
The basic breast cancer screening is comprised of palpation by a physician. If an echogram is necessary, the cost is extra. Stomach cancer is the most frequent form of malignancy among the Japanese, and it is for that reason that the government subsidy for screening is so great. Uterine cancer is relatively infrequent, but women are urged to have the screening annually after the age of 40.
Residents are free to go to any of the local centers overseen by the regional health center, and the staff recognize that many individuals receive blood pressure or other screenings at work. In the first year of the program, 14.8% of the target population took advantage of the basic physical examination through the clinic's program. In 1983 this figure increased to 38%. Cancer screening has been carried out among 26% to 28% of the three target groups as of 1983, a large increase over 1978 levels of participation in each case. This increase has occurred in spite of the extreme reluctance of Japanese to discuss cancer.
The second program, which was y recently implemented at the charge of the town government, is the nutrition development committee. This is also a volunteer program, directed by a volunteer. She works closely with the head of the health department committee and the public health nurses in coordinating efforts. So far, 73 individuals in 29 sections of the town have been selected by the community and have completed training, which consists of monthly meetings at the regional center for one year. After the basic physical examination described above, these volunteers assess the amount of salt in the individual's diet.
It is said that the most accurate way to determine the amount of salt in an individual's diet is to analyze salt content in the miso (soy protein) soup, which is served at least once each day in traditional Japanese homes. Housewives are asked to bring in samples of their soup to the clinic for assessment. The volunteers explain what composes a healthy diet and how to reduce the use of salt in cooking. Additionally, the program offers cooking classes at the local health center, so that families can actually practice new dietary habits. Once or twice per month, food is prepared and served in the homes of elderly persons who live alone. It is a goal of the center to train enough volunteers to provide this service more frequently.
COSTS OF COMMON SCREENING PROCEDURES
The third aspect of the clinic's efforts entails the work of the two public health nurses. They have undergone basic nurses' training, followed by a one-year public health certification course. In Japan the public health nurses sit for two registration examinations; the first for licensure as nurses, and the second for licensure as public health nurses. Major activities include health training in the home related to findings on physical examinations, reports from the volunteers, or self-referred needs. In the case of stroke victims, the nurses teach family members how to provide care, and they assist in activities of daily living. In addition to home visiting, for which they allow ten days per month, the nurses conduct clinics at the center, stroke rehabilitation classes, cooking classes, and occupational therapy activities, such as pottery making. They also engage extensively in collection and analysis of health-related data in their facility.
Record keeping in this center is thorough. Because the population is small and individuals are so compliant in reporting vital data to the town hall, and because of the screening efforts described above, good data exist for plotting and predicting of a wide variety of trends. Health records for each family in the community are maintained.
The five-year-old building has been designed for maximum utility. For example, the conference room doubles as the nurses' clinic. There is a large teaching kitchen with six spacious cooking areas and a large talami (strawmatted) area for group dining or meetings. Physical and occupational therapy and exercise classes are conducted in a large, carpeted room, which can be readied with portable exercise mats and equipment, such as stair steps and stationary bicycles. Finally, there is the nurses' workroom in which all records are stored.
What have been the results of this program? The most startling is the dramatically decreased death rate due to stroke for both men and women. In 1978, 52 men and 71 women died of cerebrovascular accidents; six years later the incidence rate was down to 31 men and 35 women. The program is remarkable in that volunteers have been recruited, trained, and effectively used. Also impressive is the center staff's knowledge about the community and the extent of the staff's involvement with the residents. The staffs eagerness to share their success with the authors was clear, although the capable translation of M. Kojima was essential to overcoming the language barrier.
What are the staff's plans for the future? They plan to continue expansion of the health education, screening, and nutritional counseling programs. They would like to increase the number of nurses available to help families in their homes. They especially hope to post nurses in their own communities to a greater extent than now occurs throughout the prefecture. Related to this, they are seriously considering how to recruit nurses who live in their locality - particularly those who have "retired" to full-time homemaking and child rearing - to assist the two public health nurses already serving the community. These recruitment efforts are particularly important. Clearly, the work of the staff at this local community health center has had a significant impact on the health of this town's residents.
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COSTS OF COMMON SCREENING PROCEDURES