Health Japan 21 (Stage 2) aims to reduce health inequalities, improve the social environment including social capital (social cohesion) and promote a shift to community development based on community diagnosis, even for the prevention of functional decline. However, Japan is behind Western countries regarding visualization.
Here we outline the Japan Gerontological Evaluation Study (JAGES) project funded by the Ministry of Health, Labour and Welfare Grant-in-Aids for Scientific Research etc. to address these issues and discuss potentials and challenges for increasing visualization.
First, JAGES determined the importance of benchmarks and their limitations and challenges based on a literature review, established a scheme for benchmarks in policy evaluation and indicator selection criteria and determined risks and protective factors of incident functional disability. Next, a collaborative study with 31 municipalities around Japan was conducted to build a database of over 100,000 older adults who were ineligible for long-term care, compile indicators and develop a benchmark system for providing feedback to insurers. Analyses were performed on the appropriateness of indicators based on risk factors or protective factors clarified in longitudinal studies and community intervention studies.
We discuss the framework for government-researcher collaboration, the multidimensional significance of developing a database and benchmark system and future challenges such as testing the appropriateness of benchmarks, the potential and challenges for developing a prototype comprehensive benchmark system for effective, efficient and equitable long-term care policies based on visualization of health inequalities and social determinants of health and use of big data in the field of social security.

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The World Health Organization (WHO) declares health as a fundamental human right and embraces equity in health as one of its core principles. The Final Report of the Commission on Social Determinants of Health released in 2008 cast new light on the pressing global need to ensure health equity. Importantly, it also stressed that actions must be taken not just by the health sector but also by other sectors in order to effectively create positive change among the multitude of factors that have a profound influence on people's health. WHO has since been advocating the measurement and monitoring of inequalities in health determinants and outcomes by social and geographical stratifiers, and the translation of that evidence into multisectoral actions. The WHO Centre for Health Development, based in Kobe, Japan, has been developing new tools and indicators to facilitate the implementation of these actions with a focus on urban settings and the local government level. Specifically, this paper describes the Urban Health Equity Assessment and Response Tool (Urban HEART) published in 2010, and the ongoing development of indicators of an Age-friendly City. An extensive process involving literature reviews, expert consultations, field testing and peer review is undertaken to develop these normative products. This also comes with a set of challenges in developing locally relevant yet globally applicable measures and guidance. The challenges notwithstanding, it is expected that such tools and indicators will facilitate evidence building and effective actions at both local and national levels. WHO is committed to a continuous process of reviewing and updating these products in order to maintain their optimal relevance and usefulness.

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Effective care prevention measures are needed because of the aging of society and the increasing numbers of aged people requiring care. Some means of visualizing community status factors related to care needs is important for the development of such measures. As part of such efforts, the aim of this study was to develop a set of care prevention indices. We first created a framework for the indices and listed candidate indices. After identifying good index criteria, we selected core and recommended indices from among the candidates. Then, we examined suitable methods to deal with confounders. Lastly, we used the developed set of indices to assess 31 municipalities in Japan. The result of this study was the development of a framework that consisted of five elements and two aspects and that considered the Urban HEART (Health Equity Assessment and Response Tool) framework developed by the World Health Organization. We listed 249 candidate indices using the developed framework. The good index criteria were identified as precision, representativeness of contents, acceptability by society, academic importance, modifiability, and usability of data. To address confounding, we basically adopted a stratification method because it is a method that is easy for municipality officers to understand. Finally, 22 core indices and 18 recommended indices were selected and were used to assess the municipalities. In the future, we can use this assessment tool to identify priority areas to be covered in care prevention measures.

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We critically evaluated available measures of health disparities in terms of their usefulness in local public health activities by reviewing relevant literature and calculated some candidate measures using existing data. We used survey data from JAGES, taken from 117,494 community-dwelling older (65＋ years-old) residents of 28 municipalities all around Japan in 2010/11. The results of our reviews selected range difference, range ratio, Slope Index of Inequality (SII), Relative Index of Inequality (RII), and its modified version by Kunst and Machkenbach (RII_KM) as the candidates of practically useful measures for community public health activities and community diagnosis. Then we calculated these measures for JAGES data in terms of the proportions of having depressive symptoms and not outing less than once per week. We used principal component score as district-level deprivation index. SII・RII・RII_KM for the two health measures were validly evaluated but range differences and range ratios were strongly influenced by random errors due to small sample sizes. We conclude that these measures should be widely introduced for public health practitioners and used with a good understanding of their characteristics, advantages, and limitations.

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The importance of social determinants of health has been recognized, because studies have revealed health and behaviors are affected by social environments. Its concept has been included into health policies in countries. Social capital, resources obtained from social networks, is one of social determinants of health. Social capital is considered to improve health through diffusion of health information and behavior, obtaining social support, and building healthy social norms. There are two concepts of social capital； social cohesion concept and social network concept. Former concept has been used with multilevel analysis for determining the relations of social capital and various health outcomes. Latter concept is considered to suitable for examining the mechanism between social capital and health, and for intervention studies. In addition, social capital is also important in relation to social inequalities and health, and disaster recovery settings. Intervention studies using social capital have begun to improve health of population. Further study is needed to establish social capital as an important option for building healthy society.

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It is not easy for local municipalities to make and implement long-term care prevention policies identifying their priority issues and corrective strategies based on scientific evidence. Part of such difficulty may derive from the absence of practical tools to assist the development of approaches for long-term care prevention. JAGES HEART is designed to serve as a useful tool for a cycle of defining the local agenda, developing policies, implementing programs, testing the programs through monitoring improvement, and revising approaches for further improvement. This paper introduces specific processes for supporting municipalities as they identify their agenda and tackle issues, including examples and research progress.
The recommended process for applying JAGES HEART consists of four steps： (1) setting an agenda, (2) locating target area (s), (3) planning and implementing policies, and (4) assessing the policies.
The significance of JAGES HEART lies in its holistic assistance for municipalities throughout the process of diagnosing the community, addressing the challenges, and assessing the implemented policies by visualizing objective and comparative indices. JAGES HEART has a high potential for use as an evidencebased support tool for developing long-term care prevention approaches, valuing municipalities' independence as well as local knowledge.

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