The community forum was attended by 68 participants: 10 young adults (aged 20-40 years), 18 middle-aged people (aged 41-64 years), and 40 older adults (aged ≥ 65 years). More than half of the participants were women. Despite not being explicitly asked this question, the study participants talked about what “health” meant to them at the beginning of the discussion. When the participants discussed “health”, they shared a similar goal: to be able to live independently for as long as possible (longer healthy life expectancy).
The group discussions generated the following sub-themes for health issues: 1) diseases; 2) unhealthy habits; and 3) an unsupportive environment. In addition, mental health was also considered important, with participants mentioning aspects such as stress, depression, and dementia. The discussions also emphasized the importance of social connection and communication.
(Table 1 here)
Nature was considered as a strength of the community with the potential to improve community members’ health. The research community is surrounded by beautiful forests, waterfalls, parks, and fertile land. The forum participants thought that these surrounding natural areas had the potential to be not only tourism spots, but also places to exercise (e.g., locations for walking and hiking). Many people in the community engaged in farming, from the household subsistence level to the large commercial scale. Engaging in farming activities was considered beneficial for keeping people physically active, and community members thought that older people could teach younger community residents how to perform these activities. Opening a local farmers’ market was proposed as a possibility for meeting the needs of community residents who did not engage in farming and wished to purchase vegetables at more affordable prices. This could also provide local farmers with a chance to earn money by selling their extra vegetables.
Existing community networks and communication platforms (e.g., Fureai salons or community cafés and a monthly community newsletter distributed to every household in the community) were considered the best and most practical options for disseminating health information. Collaboration with the community health office was also considered highly necessary for community health improvement. The community health office staff had been building bonds with the community for a long time, not only assisting with health activities in the community, but also participating in the community’s social activities such as primary school meetings, community center gatherings, and activities of the older adults’ club. The community health office also provided consultation on child health and long-term care services for older people, and even acted as the neighborhood onee-chan (older sister), listening to primary school and high school students’ worries and offering emotional support for people with mental health problems or cognitive impairment. Therefore, community members depended on the community health office staff members and had high expectations regarding their involvement in community health activities.
In addition to improvements within the community, improvement in health services and access to health facilities for medical checkup were also considered important. Only a few clinics operated in the community, and none of these facilities offered comprehensive medical checkups or screening. To obtain various types of cancer screenings, the community residents had to travel to several different facilities. Because public transportation did not operate frequently enough in the area, access to healthcare facilities was difficult, especially for the older adults living in the community. The relationships between each of these themes is depicted in figure 1.
(Figure 1 here)
Figure 1. Relationship between health problems, proposed action, and goals in the community
Unhealthy behaviors and an unsupportive environment were considered predisposing factors that contribute to diseases, which, in turn, affect community members’ healthy life expectancy. Improvement of services and access to medical checkups and screening, utilization of local strengths and potential, strengthening community capacity, and facilitating behavior change were thought to improve people’s health, resulting in a longer healthy life expectancy.
Of a total of 1470 households in the community, questionnaires were collected from 773 households. We categorized the participants into three age groups: young adults (aged 20–40 years), middle-aged (aged 41–64 years), and older adults (aged ³ 65 years). The proportions of men and women were balanced in the sample. The majority of the respondents had graduated from high school or above and were currently employed. More than half of the respondents reported that they practiced preventive behaviors, with eating a healthy diet, attending medical checkups, and not smoking as the most frequently reported practice. More than half of the participants seldom or never attended health-related community activities. Details on the participants’ characteristics are described in Table 2.
(Table 2 here)
We asked the participants to score the importance of community health issues and proposed actions to address them using a Likert-type scale ranging from 1 (not important) to 5 (very important). A score was calculated for each item, and these scores were ranked for each age group (Table 3). For all age groups, diseases-related health issues (cancer, cerebrovascular disease, and lifestyle-related diseases) were considered of high importance. In terms of proposed action, the participants expected that improving health services and access to medical checkups, opening vacant lots as public spaces for exercise, and maintaining collaborations with the community health office would improve community members’ health.
Similar proportions of community members were willing and unwilling to participate in a community health program, and willingness to participate was highest among those aged 65 years or older. We asked the respondents to provide their reasons for not being willing to participate in such a program, and the most frequently mentioned answers were work-related (e.g., not having enough time because work is busy, being too tired from working on weekdays and wanting to rest on weekends, and thinking of participating after retirement). Other reasons listed for not being willing to participate in a community health program were being busy as caregiver for older family members or children, being unwilling to participate in a group (e.g., wanting to participate at their own pace, wanting to avoid trouble with other people, and feeling shy in front of other people), and having no friends of the same age with whom they could participate in such a program.
(Table 3 here)
We used logistic regression analysis to determine which of the respondents’ characteristic was associated with their willingness to participate in a community health program. This analysis indicated that women, those with moderate-to-frequent past participation in community activities, those with a higher level of preventive behaviors, and those with a high commitment to the community had a relatively high odds of being willing to participate in a community health program (Table 4).
(Table 4 here)
Priority Decision and Program Development
The CAB assessed the priority of community health needs based on the results of the quantitative and qualitative data. The respondents to the questionnaire survey chose cancer as the top priority health issue, and they consequently chose the improvement of medical checkup facilities and increased access to medical facilities as the first proposed action. The participants in the group discussion mentioned the problem of the lack of a hospital that provides all the types of cancer screenings covered by the national program (i.e., screening for lung cancer, gastric cancer, colorectal cancer, prostate cancer, breast cancer, and cervical cancer). According to Nabari City data, there are two hospitals and 64 clinics in the city . Among these facilities, 34 provide cancer screening services for city residents, but none provide all types of cancer screenings . In the community we worked with in the present study, there was only one clinic that provided screenings for prostate cancer, lung cancer, and colorectal cancer. The community member participants therefore requested that a local medical facility provide integrated cancer screening services so that they would not have to travel to several medical facilities for cancer screening. In addition to the lack of service availability, public transportation to access medical facilities located in other parts of the city was also lacking. Among the participants in our study, those who were middle-aged or older were especially interested in having a community bus for easier access to these medical facilities. However, the city already conducts a mobile integrated cancer screening program in several types of locations, such as community centers, public health center, and city office . Therefore, it appears that information about this program has not been well circulated among the community residents. Although we can advocate this type of change, upgrading the medical facilities was beyond our direct reach. Seeking to improve the dissemination of health information, including information about the mobile cancer screening program, was judged to be more feasible.
Despite lifestyle-related diseases ranking second in the questionnaire survey results, interest in this health issue was quite high among the qualitative study participants. Taking feasibility into account, the CAB decided to address lifestyle-related diseases as a health issue that they could work on with direct health and social outcomes, as well as intermediate health promotion outcomes that could be evaluated in a relatively short time period.
Taking the results from the quantitative study into consideration, the CAB decided to take advantage of the local resources and centered the program on three closely related themes considered highly relevant for daily life: health awareness, exercise, and nutrition. The CAB was divided into three smaller subgroups, each of which was responsible for developing ideas for one of these themes. Each of these subgroups had CAB members representing the three elements of the larger CAB: community members, university researchers, and city officials (public health nurses or community health office staff members). After a month of developing ideas for the program, each subgroup presented the results of their discussions in a CAB meeting to receive feedback from the other CAB members, and the full CAB then decided on the final program.
For the health awareness theme, health education classes were scheduled to raise awareness and knowledge. The health awareness CAB subgroup first identified community practitioners whom they wanted to ask for cooperation. Community practitioners were considered the best option for collaborators because these individuals have many interactions with community members and have gained their trust. These individuals were therefore invited to give educational talks for the community members. With lifestyle-related diseases as the main frame, the health awareness CAB subgroup met with each practitioner to decide on topics that were relevant to each individual’s expertise to be covered in their talks. Talks on six topics were planned in the following order:
- Know your body: How to interpret the results of your health checkup
- Healthy life expectancy and how exercise and nutrition contribute to it
- Understanding lifestyle-related diseases and the importance of having a family doctor
- From mouth to health (oral health)
- Keeping your respiratory system healthy: from pneumonia to cancer, and preventive behaviors
- Chronic disease management with lifestyle and appropriate cancer screening
The nutrition CAB subgroup considered the community members’ perspectives identified in the qualitative study results and generated a variety of nutrition intervention ideas, including organizing healthy cooking classes, establishing a community cafeteria with local ingredients from local farmers, opening a farmers’ market to offer fresh foods at low prices and to promote local products, and collaborating with local shops and eateries to provide nutritional information on their products and develop healthy menus. These ideas were presented at a meeting of the full CAB, who considered the available CAB resources and time limitations and decided to begin with conducting a healthy cooking class, opening a community cafeteria, and organizing a farmers’ market every 3 months. A registered dietitian in the community collaborated with the CAB nutrition subgroup to plan the cooking and nutrition education class.
The exercise CAB subgroup planned to optimize existing activities in the community, such as the square-stepping exercise classes that targeted older residents, seeking to improve their physical health and prevent dementia. Prior to the project, this activity was offered infrequently and had just started in a few areas of the community. Through the project, it was planned to expand these classes to more areas and to offer them more frequently (monthly). Because nature was considered a community strength by the study participants (see Table 1), a group walk around the area was planned. A Hanami walk, combining walking along a planned route with the Japanese custom of Hanami, enjoying the scenic spring while sitting under sakura (cherry blossom) trees. We also planned an exercise class in collaboration with an exercise instructor who lived in the community. We selected instruction on how to correctly walk for exercise and simple exercises that most people can do at home as the topics of the exercise class, covering highly accessible, basic exercises that different populations in the community can do at any time. Finally, to encourage the use of a recently opened community lot, a community undokai (sports festival) was planned. Unlike typical Japanese sports festivals, this festival was designed to include several measurements of physical strength. The festival thus served as a means of measuring community members’ physical health. Many of these activities were planned to be held on weekends to facilitate the attendance of those who were employed.
The university researcher CAB members took primary responsibility for designing the program evaluation. First, to assess the direct health outcome of the program, we planned to conduct physical measurements before, during, and after the interventions. The measurements also aimed to raise participants’ awareness in regard to their health status. We also planned to administer a questionnaire measuring knowledge (health literacy) three times over the course of the project. Because the community health leaders in the CAB had been trained by the city to use the “daily dietary check book” , we decided to use the same tool to record the participants’ food intake. We developed a health diary based on the one used by the Ministry of Health, Labour and Welfare , with an added section to record exercise, health measurement results, goals, and target achievement evaluations. All evaluation methods were presented in a CAB meeting and revised following feedback from the full CAB. Altogether, our project was named “Healthy Akame” project.