Japan: perspectives in school health.
The school health system in Japan was established under national legislation and has a tradition beginning in the late 19th century. Its main components are health education and health services, as well as health aspects of the school environment. The system is especially highly developed with respect to its screening programs. Today, the Japan Society of School Health performs mass screening for heart diseases such as congenital heart diseases, acquired heart diseases, and arrhythmias, respiratory diseases such as tuberculosis and asthma, and renal diseases such as hephritis and nephrosis. Mas screening for heart diseases will be used to illustratie the program. Mass screening for heart diseases attempts to diagnose accurately and control systematically heart disease in the school population. This aspect of school health in Japan includes electrocardiography (ECG) and phonocardiography (PCG) and demonstrates the introduction of the school-based system of mass screening.
HEALTH CARE DELIVERY SYSTEM IN JAPAN
The evolution of Japan's medical care was influenced by the introduction of traditional Chinese medicine in the sixth century A.D. and through the introduction of Western medicine in the 1600s. Currently, the health and medical care system in Japan operates under more than 100 national laws. Implementation of most of this legislation is the responsibility of the Ministry of Health and Welfare. The activities of the Ministry include public and environmental health, social welfare, medical care financing, pharmaceutical regulation, and pensions. Japan's 47 prefectures and their local government also have roles in financing, administering, and delivering public health and social services.  Fees for procedures, medication, and other medical services are controlled by the government, with physicians, hospitals, and clinics reimbursed according to these guidelines.
Japan's population is covered by a socialized health care system established in 1961. The system is financed through a complex system of overlapping insurance plans, provided by employers and national and local governments, covering almost all citizens.  Every insured person pays a premium each month that covers the entire family; the premium rate is based on the income of the insured person. Jobless people are provided coverage paid for by the government. Thus, patients can afford most kinds of medical services, and practitioners can prescribe the requested treatments while at the same tim enhancing their financial positions. Exceptions to these coverages are preventive health care and normal delivery of a baby. Users of the health care system pay only a nominal fee at time of service; hence, per capita annual physician visits number 15, even though waiting times are long and visits are short. 
Medical care and health care are provided in two settings -- clinics and hospitals. Private doctors who usually do not have hospital privileges operate clinics. Some clinics provide only outpatient care, while others have impatient facilities with no more than 19 beds. Clinic doctors refer very ill patients to a local hospital. They work on a fee-for-service reimbursement and often have strong connections to the community, with those positions often inherited. These physicians are private, for-profit providers, and the often receive both money and gifts as compensation from patients.
Hospitals include all facilities with 20 beds or more. Most are private, physician-owned institutions. Larger regional hospitals generally are public institutions and usually are affiliated with medical schools. Physicians in the public hospitals are employees of the hospital and are paid fixed monthly salaries from the institution, regardless of the number of patient visits. They are responsible for inpatient as well as outpatient care.
There are many challenges to the current medical system in Japan. Medical expenditures are rising rapidly, faster thay any other goods or services. There is a growing number of new physicians and a potential over supply in the near future. This is the result of the policy establishing, as of 1970, at least one medical school in each prefecture. Many new physicians choose to work in urban hospitals and to specialize rather than establish general practice in the community. A hospital position is seen as very desirable becuase of increasing salaries, prestige, and the teaching environment. With an increase in the extect of outpatient services provided by public hospitals, this development is seen in a sense as a threat by clinic physicians.
Other challenges to the health care system are due in part to strong resistance to invasive procedures. Bed rest and prescription medications are preferred to surgery whenever possible, and diagnostic equipment is used extensively. The average length of a hospital stay is 39 days; the longer the stay, the greater the reimbursement for the hospital. At present, few intermediate care facilities exist; patients who no longer require acute care are maintained in a hospital if unable to return home. In addition, medications are dispensed frequently, with clinic physicians being allowed both to prescribe and to dispense drugs. Iglehart  indicated that "heavy prescribing is endemic' and that the per capita consumption of pharmaceuticals is higher in Japan than in any other country.
Another major concern is the medical system's ability to cope with a rapidly aging population. Elderly are covered by health insurance financed through the national government, local governments, and contributions from employee health insurance and community health insurance plans. Estimated project that by the year 2020, the population of Japan will have one of the highest proportions of older persons in the world, and the elderly will place a great burden on the country's medical and social services. Japan presently does not have the facilities needed for chronic, long-term care, nor do many families have the space to care for an elderly relative. Further, increasing numbers of women who might have provided such care are now working outside the home.
THE EDUCATIONAL SYSTEM
Japan's educational system underwent major reform in the early years of the Meiji Restoration, beginning with a cabinet decree in 1872 that established a three-stage system of elementary school, middle school, and university education. Only the first four years were then compulsory. Several important modifications occurred in the following decades, but substantial revision of the system was introduced after World War II.
In 1947, the single-track system, based on a 6-3-3-4 sequence of elementary, middle, and high school curricula and university, was adopted. Preschool facilities also have been established, consisting of both nursery schools and kindergartens. Following high school, the educational system includes junior colleges, vocational schools, and graduate schools as well as four-year universities. At all levels, special schools are provided for those with mental or physical handicaps. Attendance through the middle school is compulsory, and although traditionally education was less common for females, enrollment of females is now at least as frequent, proportionally, as that of males. In this article only those aspects which apply for elementary through high school grades are described. 
SCHOOL HEALTH PROGRAM OVERVIEW
The Japanese school health program began in the Meiji period (1868-1912), and the original Japanese "Law of School Health" was established in 1924. In 1958, this law underwent its first revision. The Japanese Law of School Health concerns infectious diseases, heart diseases, renal diseases, dental care, and other conditions. Recently, psychological disorders, essential hypertension, and obesity are becoming problems. Although mass screening for heart disease was first performed in 1954 in Osaka City, the examination was limited to cardiac auscultation, completion of a questionnaire, and chest radiography. In 1958, the Ministry of Education again considered this to be the recommended method of screening for heart diseases.
In 1967, the Ministry of Public Welfare defined the criteria for diagnosing and supervising students with heart diseases and reaffirmed the 1958 recommendation. However, these criteria did not yet include electrocardiographic (ECG) and phonocardiographic (PCG) examinations. In 1971, Mori performed mass screening for heart disease, including ECG, in Kyoto and Nobuoka cities and insisted on the importance of examinations for all subjects. 
The Law of School Health was revised in 1973, and mass screening for heart diseases and renal diseases became obligatory in school health examinations. In 1975, the Ministry of Education further developed the system of mass screening for students to identify those with heart diseases.
The Japan Society of School Health is an agency that includes several committees, such as the Committee for Heart Diseases. The Committee for Heart Diseases comprises, pediatric cardiologists, school doctors, regular teachers in contrast to specially trained health teachers, private clinic doctors, and governors. In 1981, the committee published the Practice of School Examination for Hearth Diseases textbook, described the system of mass examination, and explained its significance. An explanation of heart diseases for teachers was included. The Committee for Electrocardiography in Children of the Japanese Society of Pediatric Cardiology has laid down such provisions as criteria for diagnosis of left ventricular hypertrophy,  criteria for diagnosis by simplified four-lead ECG,  and standards for control of children with arrhythmias. 
Since the early 1980s. new systems, including the ECG and PCG in primary examinations and diagnosis by use f automated computer analysis, have been used. A Congress on Child Health and a Conference on Children and Adolescents with Heart Diseases hasbeen held annually, and are usually attended by teachers and school physicians. When teachers and school physicians identify children with heart diseases, pediatric cardiologists usually supervise such children to provide optimum management in shcool.
Qualification of health teachers include either graduation from a university or college or from a nursing school. In the former case, special training includes courses in medicine. In the latter case, a one-year program in health teaching is required. Duties of these health teachers include both instruction for students and the management of school health programs.
The school health concept has two aspects -- health instruction and health control. According to school health policy, the main purpose of health education is to raise each child with a healthy body and spirit, and to that purpose, it is necessry to provide for instruction, physical education, and health care. The Japanese Law of School Health concerns the control of health and encompasses health examinations, prevention of infectious diseases, and the appointment of school physicians, dentists, and pharmacists. Mass screening for heart diseases is included in health examinations.
Local principals, who are responsible for supervising and managing their schools, organize the physical education curriculum. The curriculum must be in keeping with the rules and concepts of public education, as expressed in the Japanese School Education Law.
The aim of health education is to maintain and improve the students' health in school. Health education in school is based on the system outlined in Figure 1. Although in Japan the term "physical education" is sometimes used (as in Figure 1), it corresponds to what in some systems would be designated more broadly as "health education." Five principles apply to this concept as it is understood in Japan.
1) Health education as defined in the curriculum aims to create an understanding of an elementary knowledge of health and safety.
2) Health education in school aims to promote practical activities to live safely and in good health.
3) Health education guidance in class aims at teaching concrete methods to live safely and in good health.
4) Health education in school life aims at fostering the ability to identify health and safety problems and solve those by oneself.
5) Health education, when taken as an added elective subject, aims at further development of skills useful in maintaining health and safety.
Figure 2 illustrates the system of health guidance in school education.  The scheme denotes both the formal and the informal elements of health guidance provided to students in the school setting.
Specific prevention programs in the areas of substance abuse are not traditional, in that these problems are not common in Japan. However, there are perceptions that the frequency of such behaviors is increasing, and efforts to cope with them are being undertaken especially in major cities such as Tokyo. Student behavior in public places is sometimes monitored by parents, who warn students about the attendant hazards.
The role of the school in providing health services is defined in Article 23 of the Japanese Law of School Health. The school doctor can be a physician, dentist, or pharmacist and must perform the functions of the otorhinolaryngologist, oculist, and pediatrician. Some health data are obtained by teachers, including the health teacher, such as body weight, height, certain measures of behavior, past health history, and family history. School physicians also conduct mass screening programs in accordance with the scheme outlined in Figure 3.
Mass screening for heart and renal diseases, among others, is considered to be an important aspect of examination forocular diseases, permitting their control. Urinalysis testing has been performed in all students since 1978. Because carious teeth were observed in more than 90% of students, mass screening for dental diseases is one of the most important components of the school health program. The health teacher must assemble the data on body weight, height, blood samples, and the results of mass screening to discover signs fo such conditions as obesty, orthostatic dysregulation, scoliosis, and anemia. Finally, health teachers discuss these problems with school physicians and must advise children with disorders regarding special care, extra consultations, or therapy.
Mass screenings are finished by June (the school year begins in April), and health teachers conduct health counseling based on these data. Health counseling is guided by health teachers and involves teachers in charge, students, and parents. The physician who performed the dental screening joins the discussion. Health teachers must keep a counseling record and must contact the family physician or specialist, as appropriate. Counseling with parents was formerly taken care by school doctors, in accordance with the Japanese Law of School Health. Recently, however, the school physician's role has gradually grown to include additional responsibilities, so that health conseling is now performed by health teachers.
Management of the environment is another important aspect of the school health program. The Japanese Law of School Health, as revised in 1978, emphasizes the importance of a healthy environment. Specific checks to be conducted each year are:
1) quality of drinking water, pool water, and drainage,
2) disinfection of the water, pool water, and drainage equipment,
3) classroom lighting and general illumination,
4) ventilation and the heating and noise levels of the classrooms, and
5) and additional problems specified by the principal.
Recently, one more important environmental problem relating to schools are various public nuisances, such as traffic accidents, noise, and air pollution.
Another aspect of the health-related environment concerns the diet of schoolchildren. School lunch in Japan was introduced in 1889. In 1923, the Ministry of Education encouraged school lunch as an aspect of nutritional improvement. After World War II, the system of school lunch was reestablished by the Ministry of Education, the Ministry of Public Welfare, and the Ministry of Agriculture and Foresty because of an aggravation of the food situation. Table 1 shows the current situation regarding school lunch.  For each school level, numbers and percentages of participating schools and students, respectively, are shown. All public schools participate, but for private schools, this choice is made by the Parent-Teacher Association. For example, the percentages of children using the school lunch program ranged from 99.5% in the 24,421 participating primary schools to 82.1% in the 740 participating special schools.
In recognition of the importance of family-school-community relationships, school health committees have been established (Figure 4).  School representatives include principals and other teachers, all who have responsibility for aspects of the health program. Parents are represented through the Parent-Teacher Association and its standing committees. The community is represented by members from education, health, and welfare agencies. Student representatives also may participate.
Mass screening in Japan's school system serves not only for case detection and disease control but also offers an opportunity for research aimed at longer term benefits to children's health and their later health as adults. Reports concerning school health in Japan are published in the bimonthly Japanese Journal of Juvenile Health. Recenty, reports concerning mass screening have become more frequent, especially those concerning mass screenign for obesity, cholesterol, hypertension, and congenital and acquired heart diseases. [12-15] Mass screening examinations for heart diseases, as performed in Shimane Prefecture, illustrate the mass screening under way in the Japanese school health program. 
A mass screening system is outlined in Figure 5. All children and adolescents in primary, junior, and senior high schools are screened at ages six, 12, and 15. Primary screening is performed with a questionnaire for heart diseases, including Kawasaki syndrome (checklist), physical examination by the school physician, simplified four-lead ECG (I, aVf, Vi and V6), and indirect chest x-ray film. A computer-equipped automatic analyzer for ECG and PCG also was introduced. The questionnaires, ECG, and chest x-ray films are checked by a pediatric cardiologist at the Dept. of Pediatrics, Shimane Medical University Hospital. A second examination is recommended on the basis of these results.
Skimane Prefectue, situated on Japan's western coast, is 220 kilometers long and includes remote mountain and island areas in addition to urban communities. The population was about 600,000 in 1988. Because of these geographical peculiarities, the secondary examination of mass screening (Figure 5) was performed before the "precise" or tertiary examination at Shimane Medical University. Secondary examinations were performed at 11 sites and consisted of auscultation by a pediatric cardiologist, a standard 12-lead ECG, and a Master's double step test. A further, more precise exam was recommended for the 5% to 10% of cases selected for this screening. This examination was performed at the Dept. of Pediatrics, Shimane Medical University Hospital, the only hospital in Shimane Prefecture capable of such diagnosis by pediatric cardiologists. The number of subjects in the primary and secondary screenings and tertiary examinations (initiated in 1981) are provided in Tables 2 and 3.
Mass screening in Shimane Prefecture started in 1977, and the numbers of participants gradually have increased. Especially since 1980, when Shimane Medical University Hospital was opened, the numbers have increased to more than 20,000 per year. In 1980, most senior high schools in Shimane Prefecture performed mass screening for heart disease with ECG. Primary and junior high schools participation was initially less than 50% in Shimane Prefecture. This percentage increased gradually, and by 1982, mass screening was performed in more than 95% of primary and junior high schools.
As shown in Table 2, recently 2.9% of participants showed abnormal findings by simplified four-lead ECG. These abnormalities included conduction defects, left ventricular hypertrophy, and other conditions. All ECGs were read by pediatric cardiologists in the Shimane Medical University or other national hospitals. In some cities, computerized ECG recording and diagnosis were used. From 0.1% to 0.3% of subjects were found to have abnormalities at secondary screening, and the most recent percentage of clinically significant heart diseases was about 0.02% of all subjects.
Table 3 shows the number of heart conditions, including arrhythmias, that were not under the supervision of the pediatric cardiologist at the time of mass screening. Seventy-three cases were discovered from 1982-1988. Data analysis began to be performed from 1980 when Shimane Medical University Hospital was opened. Most of those children with ventricular septal defects and patent ductus arteriosus were discovered in 1980 and 1982. Children with atrial septal defects have been discovered every year, and one-third of them could not be identified at the age of six or 12. A trial septal defects were mainly discovered by ECG examinations (Table 4). Some cases of arrhythmias such as Wolf-Parkinson-White syndrome, premature atrial condition, and premature ventricular contraction, have been discovered every year.
Although in 1978, the Japan Society of School Health recommended mass screenings should be performed, the recommendation included neither PCG nor ECG examinations. Shimane Prefecture had begun mass screening for heart diseases earlier than in other areas of Japan and also performed mass screening, including PCG, starting in 1983. On the basis of experience in this program, mass screening for heart diseases has been recommended to include PCG and not only the 12-lead ECG.
Kawasaki syndrome, which is of special concern in Japan, sometimes produces coronary lesions, and some patients are at high risk of sudden death. However, ECG and PECG are not useful to discover coronary obstructive and aneurysmal lesions. Thus, parental questionnaires are used in mass screening to discover a history of Kawasaki syndrome. When the history is positive, the health counseling process can include giving parents a clear understanding of the symptoms of Kawasaki syndrome and alerting them to potential emergencies.
Finally, based on this experience, criteria have been advanced for diagnosing and evaluating ECG findings in mass screening.  Consequently, the Japanese Society of Pediatric Cardiology assessed this screening system and accordingly has established such criteria for both diagnosis and management of patients. in this way, the pratical outcome of the school health program, illustrated by heart disease screening, has led to useful programs in the school and more general development of methods of diagnosis and treatment of heart diseases in children in Japan.
FUTURE CHALLEGNES AND PLANS
FOR SCHOOL HEALTH
School health programs, initiated in the late 19th century, have been credited with important contributions to the health of people in Japan. The school lunch program is believed to have improved growth and physical well-being, ECG examinations are regarded as successful in early identification of heart disease, and reduced incidence of infectious diseases is attributed to the health teacher's role in school health.
From the aspect of prevention of adult diseases, the establishment of a mass screening system for children is considered in Japan to be important. Mass screening for hypertension, cholesterol, and obesity will be extensively performed with standardized methods. Recently, a computer-equipped automatic analyzer for ECG and PCG is being widely used. Although the computer-equipped automatic analyzer system appears adequate to screen out heart diseases at this moment, it is considered to be impossible to replace a pediatric cardiologist where accurate diagnosis of specific heart diseases is concerned. However, the automatic analyzer system eventually may replace pediatric cardiologists in mass screening because the system saves personnel expenses. 
On the other hand, behavioral problems will become more important. These problems should be considered and managed not only by health teachers but also by school doctors. Kobayashi  insisted that the concept of new morbidity and new mortality, including psychosomatic diseaseS, behavioral problems, AIDS, and preventable risks of geriatric diseases, should be introduced into the school health program. The principle of the computer analyzer, using human ecology and medical anthropology as well, will be applicable in efforts to address and solve these new problems and not only the continuing ones of heart disease detection.
In recent years, some new disease components have been added to the school health program. In 1989, the Ministry of Education recommended performing scoliosis and dental caries examinations; infectious disease prevention has come to include attention to hepatitis B, AIDS, and adult T-cell leukemia virus. New education techniques have been introduced, incorporating video programs.
Finally, the research setting of the schools can be developed much further in the interest of improving the health of children now and in their adulthood. Linked to the screening program described in Shimane Prefecture is the Shimane Heart Study, whose results are illustrated by reference.  Not only is this study an outstanding example of school-based health research in Japan, it is the starting point for an international comparative study between the U.S. and Japan. Other school systems, in other areas of the world, might well be linked in a similar way for meeting future health objectives.
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Koji Watanabe, MD, DMSc; Chuzo Mori, MD; and Noriyuki Haneda, MD, Dept. of Pediatrics, Shimane Medical University, Izumo, Japan; and Jo Anne Grunbaum, RN, EdD; and Darwin R. Labarthe, MD, PhD, School of Public Health, The University of Texas Health Science Center at Houston, P.O. Box 20186, Houston, TX 77225.
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|Title Annotation:||Special Issue: International Perspectives on School Health|
|Author:||Watanabe, Koji; Mori, Chuzo; Haneda, Noriyuki; Grunbaum, Jo Anne; Labarthe, Darwin R.|
|Publication:||Journal of School Health|
|Date:||Sep 1, 1990|
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