Community-based care for healthy ageing: lessons from Japan

Abstract Problem The measures for long-term care prevention that the Japanese government had introduced in 2006 were unsuccessful because of the failures to identify high-risk individuals and to enrol enough participants in the community prevention programme. Approach The Japanese government shifted its primary strategy from a high-risk strategy to a community-based population strategy in 2015, by reforming the Long-term Care Insurance Act. This act is focusing on community-based care and social determinants of health. The Act and the government’s plans for long-term care prevention are inspired by a social participation intervention called ikoino saron, that is gathering salons for people older than 65 years. These salons, managed by local volunteers, are held once or twice a month in communal spaces within walking distance of community members’ homes and have a low participation fee. At the gatherings, older people can meet and interact with others through enjoyable, relaxing and sometimes educational programmes. Local setting Japan has the world’s largest ageing population, with 27.7% (35.2 million/126.7 million) of people older than 65 years. Relevant changes Studies have shown that participation in the salons was associated with a halved incidence in long-term care needs and about one-third reduction in the risk of dementia onset. Evidence also suggests that financially vulnerable older adults were more likely to participate in such interventions. In 2017, 86.5% (1506/1741) of the Japanese municipalities had implemented the salons. Lessons learnt Integrated care for long-term care prevention should consider interventions targeting the whole community in addition to high-risk individuals.


Introduction
Japan has the world's largest ageing population. In 2017, 27.7% (35.2 million/126.7 million) of people living in Japan were older than 65 years. Over the years, the Japanese government has reformed its policies to respond to the need of the ageing population and to prevent long-term care. In 2006, the government implemented measures aimed to identify frail or semi-frail older adults (that is, 65 years or older) and provide early preventive care programmes for functional decline, to delay dependence on long-term care. The measures consisted of identifying older people with disability risks, by screening them, mainly at regular health check-ups, using a validated one-page questionnaire (Kihon checklist). 1 Identified high-risk individuals were subsequently referred to free community prevention programmes.
However, the measures failed to identify high-risk individuals and participation in community programmes was low. Based on available evidence, the government estimated that approximately 5% of the total older population was at risk, and therefore should be the target of preventive care. However, in 2014, by the ninth year of strategy implementation, only 0.8% (267 654/32 824 841) of older adults had joined the community prevention programme. 2 This result was due to the low participation in the screening process for functional difficulties: only 34.8% (11 408 862/32 824 841) of older people participated, a lower percentage than that for regular health check-ups (41.5% for 65-74-year-old people). 2 Although supportive evidence is not available, we speculate that physical and environmental barriers and the lack of support to overcome these barriers, such as incentives and transportation, may explain the low participation. The low screening participation could also increase inequities in preventive service provision.
A community-based survey identified that the proportion of socially disadvantaged people undergoing health check-ups was low. 3 Moreover, the screening programme created ethical debates because the Japanese government categorized the older adults identified as frail as "special elderly" (tokutei koureisha). Some researchers and policy-makers were concerned about potential labelling and stigmatization, and in 2010, the government changed the name to "target individuals for secondary prevention programmes" (niji-yobou taishousha).
The low participation in the community prevention programmes resulted in limited attributable impact. In theory, even if the government succeeded in providing the programme to all eligible persons, these only represented 5% of the total older population. However, work on disease prevention, suggests that the distribution of disease and risk is generally a continuum, without an exact boundary between the normal and abnormal and that people developing a disease could be identified as normal in a screening programme. 4 In Japan, half of those who developed functional decline did not belong to the high-risk or special elderly group before their functional decline started. 5 The government recognized the issues associated to the secondary prevention measure, that is, difficulties in maintaining participants' motivation and high discontinuance rates and hence revised its policies for preventing long-term care. 6 Here we describe the country's current strategy and we focus on a social participation intervention called ikoino saron, that is, salons where older people can gather.

Current strategy
In response to the increasing awareness on health inequality, the second term of the National Health Promotion Movement: Lessons from the field Integrated care for health ageing, Japan Junko Saito et al.
Health Japan 21 (2013-2022), started including the social determinants of health. Specifically, public long-term care prevention plans now focus on promoting social participation and preventing isolation of older people, since isolation has been identified as a strong risk factor for long-term care and premature mortality. 7,8 In 2015, the government reformed the Long-term Care Insurance Act, by changing its primary strategy for longterm care prevention from a high-risk strategy to a community-based population strategy. The new strategy aims to build a community that can seamlessly provide preventive, medical and longterm care, welfare and housing services to all individuals. Based on the population strategy for long-term care prevention, central and local governments have promoted community activities, such as salons, to facilitate group participation and encourage social activities among older adults.

The salons
The current Act and health promotion plan have been inspired by a project started in 2007 in the municipality of Taketoyo. The municipality, in collaboration with citizen volunteers and researchers, established social gathering opportunities for older adults. At these gatherings, older people can meet and interact with others through enjoyable, relaxing and sometimes educational social programmes, such as arts, crafts, music, health education seminar and physical and brain exercises. 9 In 2013, there were 10 salons across Taketoyo and more than 10% (875/8062) of the eligible population attended these salons. Once a salon is established, local volunteers manage it with partial financial and administrative support from the townhall. The salons are held once or twice per month in communal spaces and a session last about two hours. Typically, 20 to 60 older adults attend one session, but large events may attract up to 100 people. 9 To ensure accessibility and equal opportunities, the salons are within walking distance for most of the participants from their homes and the participation fee is only 100 yen (about 1 United States dollar) per visit. The project aims to provide a variety of activities that both promote health and enrich life, and to foster community-level social capital by encouraging community engagement. 9

Relevant changes
In 2017, this salon-type community interventions were used in 86.5% (1506/1741) of the municipalities in Japan. 10 Two studies in Taketoyo estimated that participation in the salon was associated with a halved incidence in long-term care needs and about onethird reduction in the risk of dementia onset. 11,12 In a survey from the municipality of Tokai, 88 salon participants (out of 187 surveyed) answered that the salon increased their opportunities to go out, 117 (out of 188) responded an increased interaction with others and 56 (out of 183) responded that they were more likely to start participating in other social activities in the community. 13 Furthermore, in seven municipalities, the proportion of high-risk individuals who participated in the salon to the total older population was almost twice as high as the proportion of high-risk individuals who participated in nationwide conventional secondary prevention programmes, based on the high-risk strategy (1.5%; 1535/100 593 versus 0.8%; 267 654/32 824 841). 14 The difference could be due to the fact that the salons target all older people, including people who have limited access to adequate medical or social welfare services, as well as the low participation fee and the short distance from home to the venues. In 2007, the proportion of salon participants from low-income groups in Taketoyo was higher than that from high-income groups (8.0%; 6/75 versus 5.5%; 16/293 for men, and 19.0%; 47/247 versus 6.5%; 2/31 for women). 9 These results suggest that salon-type community interventions may reduce the inequalities in social interactions.

Lessons learnt
Shifting from a high-risk strategy to a population strategy involving multidisciplinary community collaborations has been successful in Japan. We learnt that for community-based integrated care systems to succeed, collaboration between community members and diverse service providers was indispensable. For instance, community members collaboration with local government staff was crucial for the sustainability of the interventions. The collaboration allowed community members to create or modify their own community welfare services in line with their needs and local situations (Box 1).
We also learnt that quantitative health equity assessments and visualizing the results in an easily understandable manner were useful in identifying and prioritizing problems, as well as sharing community goals of local actions and policies with service providers and community members. The Japan Gerontological Evaluation Study initiative have developed the Health Equity Assessment and Response Tool, in collaboration with the World Health Organization (WHO) Kobe Centre, which developed the urban version of the tool. The tool includes indicators for social determinants of health and allows users to assess health inequality within the city or across cities. This online tool has been used by local care providers to show trends in levels of long-term care risks and community resources for interventions. 15 In 2017, WHO published the Guidelines on integrated care for older people, to provide guidance on preventing, slowing or reversing the decline of the intrinsic capabilities of older individuals and maximizing their functional abilities. 16 The guidelines make evidence-based recommendations for the comprehensive assessment of the health status of older people and delivery of integrated health care. Most of the guidelines recommendations involve secondary prevention measures, that is, identifying frail people aged 60 years or older, and providing them with preventive care. However, as supported by Japan's experience, secondary prevention measures or screening of high-risk individual needs

Box 1. Summary of main lessons learnt
• Integrated care for long-term care prevention should consider interventions targeting the community rather than only high-risk individuals. • Salon-type community interventions proved effective in reducing long-term care needs and dementia, and may help reduce health inequalities. • Multidisciplinary collaborations among diverse service providers and community members are indispensable for providing community-based care.
Lessons from the field Integrated care for health ageing, Japan Junko Saito et al.
effective screening measure to identify high-risk individuals, effective interventions to mitigate possible risks and effective means to deliver the intervention to high-risk individuals. 4 We suggest, with the support of the empirical evidence gathered, 9,[11][12][13][14][15] that integrated care for long-term care prevention should include more community-organized interventions for the whole community. To build local organizational networks for providing such care, health-care workers and organizations should be actively involved. The Japanese concept of community-based integrated care corresponds to local governance mecha-nisms in WHO's ongoing programmes, including Healthy Cities and Healthy Ageing. The concept is also in line with the three recommendations of the final report of the WHO Commission on Social Determinants of Health, that is, improving daily living conditions, establishing good governance to secure equitable resource allocation and making health equity assessment. Eventually, the concept would help achieve universal health coverage. With these lessons from Japan, we suggest that WHO adds the perspectives of community-based care and social determinants of health to integrated care strategies. ■