Priority Health Issue
Both participants in group discussion and questionnaire survey put priority on diseases as health issues they were concerned about. Among the number of diseases mentioned, cancer was the priority for all age group. Cancer has been number one cause of death in Japan, and also huge contributor as the cause of long-term care needs.(2) There have been various campaign about cancer, so it was expected to be one of the concern for community members.
Lifestyle-related diseases (metabolic syndrome, obesity, hypertension, diabetes mellitus) and cerebrovascular diseases came as the second and third rank in the priority score. For middle-age group participants lifestyle-related diseases rank higher than cerebrovascular diseases, and vice versa for older adult group. This result resonates with the onset of the respective diseases. Type 2 diabetes mellitus and hypertension can be found from middle-age adulthood, and even earlier in young adults.(23,24) Meanwhile, the average onset of cerebrovascular disease is in the later adulthood, affecting more older adults compare to middle-age and young adults.(25) It showed that people’s concern and decision of priority for health problems reflected the epidemiology of the diseases, which might have affected the individual or their family and relatives.
While participants in group discussion put emphasize on unhealthy behavior problems, the questionnaire survey results showed that unhealthy behaviors were not in the top 5 priorities. It was peculiar to see that despite lifestyle-related diseases was ranked high for all age groups, the unhealthy behaviors which cause the lifestyle-related diseases were not considered as important. This result showed that majority of people’s perspective about health still centered in the absence or existence of diseases, lacking the recognition of unhealthy behaviors as risk factors for the diseases. Those who attended the community forum and participated in group discussion might be people who have higher awareness about health, thus they put on the importance of unhealthy behaviors problem. Rongen, et al identified that participants with positive attitude toward health promotion, belief that health promotion was good, and perceived that they need to improve their health, were more likely to attend health promotion program in workplace.(26) Another study conducted in Japan regarding the knowledge about cancer’s risk factors showed that majority of respondents answered infection as the most attributable factor for cancer, higher than other lifestyle-related risk factors.(27) Our study participants’ might also have different perception about risk factor to diseases, and it requires further investigation to confirm it.
Smoking and alcohol drinking were least prioritized, placing last in all age group. From the prevention practice, we can see that only around 58% participants practiced non-smoking, and even less who practiced no alcohol drinking (33.8%). It means large numbers of participants were drinking alcohol and smoking. This number is higher than the Japan’s national average of smoking which is 17.8% for all adult population.(28) Japan has enforced several policies on smoking that resulted in decrease number of adult smokers from 21.8% (male 36.8%, female 9.1%) in 2008 to 17.8% (male 29%, female 9.1%) in 2018.(29) However, the daily smoking percentage in overall is still high.(30) In the past decade, the percentage of smoking in enclosed space (school, offices, restaurant, etc.) has been decreasing significantly, but not in open space (public transportation area, kids playground, street, etc.).(29) Compared to other OECD countries, Japan’s anti-smoking policy is still lacking and further enforcement is necessary to foster a free smoking environment.(28) In addition to that, drinking alcohol is common in daily life, with a lot of social meeting come along nomikai (drinking party).(31–34) Since smoking and drinking alcohol have become part of the Japanese social life, it might be more difficult for people to see and perceive them as problem. The harm effect of alcohol and tobacco consumption for health are well-known and have been researched extensively.(35–37) Tackling these two problems will reduce risk factor for diseases and beneficial for people’s health. It will take government’s commitment for policy and program enforcement, as well as social norm change to raise awareness about the harm of tobacco and alcohol, and its effect on health and society.
Amidst the lack of recognition of unhealthy behavior as important health issues, young adult respondents of questionnaire survey chose sedentary lifestyle and lack of public facility to exercise in the top 5 for priority health issues. It reflected that the young adults who responded to the questionnaire might have better understanding about the health consequences of physical inactivity and felt that availability of public places for exercise can facilitate them to resolve the problem.
Plan of Action
Relevant to cancer as the top priority health issue, respondents of our study chose improvement of medical checkup facilities and access to the medical facilities as first proposed action. Respondents in the group discussion raised the problem of having no hospital that provide all cancer screening covered by the national program (lung cancer, gastric cancer, colorectal cancer, prostate cancer, breast cancer, and cervical cancer). According to Nabari city data, there are 2 hospitals and 64 clinics in the city.(38) Among them 34 facilities have been providing cancer screening services for the city residents but none provide all cancer screening.(39) In the community we worked with, there was only one clinic that provide screening for prostate cancer, lung cancer, and colorectal cancer. Therefore, people asked for medical facility that can provide integrated cancer screening, so they do not have to go around several medical facilities. In addition to the lack of service, public transportation to access medical facilities in other part of the city was also lacking. The middle-age and older adults especially expected to have community bus for easier access to medical facilities. However, the city has actually been conducting mobile integrated cancer screening program in several places such as community center, public health center, and city office.(22) It seems like this information has not been well-circulated among residents. Since upgrading medical facility was beyond our reach, we can only advocate for it. Meanwhile, improving dissemination of health information, including about mobile cancer screening, was considered more feasible.
Other proposed actions were things that can be improved, or utilization of local resources in the community. Nature was one of thing highlighted during the group discussion. The existing waterfall and mountainous area which were famous for tourism and hiking place were considered as community treasure. Review article written by Maller et al summarized some health benefits of contact with nature, including being an effective way to relieve stress, improving well-being, and eliciting parasympathetic nervous system which associated with restoration of physical energy.(40)
The fertile land was used by community residents for farming, mostly for family consumption. Opening local farm market can facilitate meeting the needs of consumer, community residents who did not farm and wished to purchase vegetables with more affordable price. It can also provide chance for local farmers to gain profits by selling the extra vegetables that they produce. Like any other rural areas in Japan, household farming activities were mostly done by the older adults.(41) While young and middle-age adults in our study expressed interest for agriculture class to learn farming method or being the consumer of farmer market, the older adult group might not find it important or as interesting, since it was just a routine activity for them.
Collaboration with community health office and improving dissemination of information were also considered as highly necessary for the community. Established 15 years ago, the staff of community health office had been there for the residents, assisting health-related activities in the community.(42) Despite mainly provide consultation service for long-term care and child health, they have been involved in other community activities of all age such as primary school meetings, community center meetings, and activities for the older adults’ club.(43) They accepted consultation for child’s health, long-term care services for older people, even acted as the neighborhood onee-chan (older sister in Japanese) who listen to primary/high school students’ worries and gave emotional support for people with mental health/cognitive problems. Therefore, people had high expectation and dependence for their involvement in the community health activities.
Even though internet-based information is getting more popular, majority of respondents in this study considered the local newsletter that was distributed to all households as the best and most feasible option for health-related information dissemination. Study about health information seeking behavior found that those who were younger, more educated, and more internet skilled were better in taking advantage of finding health information from the web.(44) Meanwhile, our participants majority who were older adults might be more comfortable with conservative information dissemination. However, this type of print communication required active information seeking behavior from the readers. If the readers do not actively try to look for health information, then the newsletter will be left unseen and information cannot be transferred to the target. Other forms of communication, which were intergenerational communication and social meet-up event, were highly expected among group discussion participants. Several previous studies have showed benefit of intergenerational activity for expanding social network, also improving health and quality of life of the study participants.(45–48) Unfortunately, it was not considered as highly important for majority of residents who responded to our questionnaire.
Initiation of exercise classes and sports event, as well as utilization of the recently established open space for exercise were pointed as high importance both in the group discussion and questionnaire survey. Being physically active has been proven to lower all-cause of mortality, including from cardiovascular diseases and cancer.(49–51) Promoting physical activity can lower one risk factor to prevent diseases in the later phase of their life, and open the door for health promotion activity to attract the young target group. In addition to physical activity and exercise program, introduction of healthy diet and cessation of unhealthy behaviors are expected to reduce the prevalence of cardiovascular and metabolic diseases, as well as cancer.(35,49)
Determinants of Participation in Community Health Program
We found that female was more likely to participate in community health program, and this result was found in other previous studies across countries. A recently published study from Canada showed that more rural women wanted to participate compared to men, and men were more likely to report being too busy.(52) Consistently, study in Finnish population also showed that women were more interested in seeking health information.(53) Anderson, et al found that women outnumbering men in program implementation had caused men became more reluctant to participate.(54)
People who have high commitment to their community were more likely to attend community activities in the past and were also willing to participate in the future community health program. In addition, people who had high awareness of healthy behavior and practiced them were also more likely to attend. In contrary, people with higher degree of education (college/university graduates) were less likely to participate. In this area of unlimited information, people can access health information easily with assistance of technology. Jansen et al showed that people with higher education level might also have good health literacy.(55) Therefore, these people might have better in understanding health information, using health care services and resources, and felt less necessary to attend certain program in the community.
Limitations
Participants of this study were mostly older adults, and only few young adults participated. The opinion obtained in this study might not reflected the needs of younger generation, who were also targeted for the program. We also have not involved the local medical practitioner actively in this study. While community needs and opinion for plan of action are important, it is also necessary to receive opinion from the practitioner who provide medical services to the people in the community. The wall between medical and health sector existed in Japan’s healthcare. For lay person, medical professionals are considered in higher position so the community members were reluctant and felt afraid that they would burden the busy medical professionals. For better collaboration in the future, the active involvement of medical professionals is essential for the effort of improving people’s health. This study was specific for the community we worked with. While other rural Japan communities might have similar characteristics, other values and culture might result in different outcome with our study. However, the research method and approach that we used in our study can be applicable for any other community.