A Review of the Literature on the Regional Strengths Perceived by Older People Living in Local Japanese Communities

Abstract

As a super-aging society, health promotion activities in local Japanese communities are increasingly essential. Developing the health-promotion programs must include the perspective of older people residing in these communities and what they believe to be their regional strengths. This study aimed to clarify the elements of regional strengths perceived by older people living in local Japanese communities from the literature review. Using the internet edition of the Japan Medical Abstracts Society (Ichu-shi), the authors examined papers on Japanese regional residents using relevant keywords. Of 342 considered papers, 14 papers were extracted in this study. As a result, the contents related to the regional strengths perceived by the older people living in the local Japanese community were extracted, classified based on the similarity of the meanings and contents, and then summarized into the elements of the strengths. As the regional strengths, three categories were cited for individual elements: “Actions or behaviors underpinned by experience,” “Continuing to live with positivity and vigor,” and “Extensive support for the subject and their family.” Three categories were cited for environmental elements: “A comfortable environment,” “Maintaining intimate and friendly interpersonal relations,” and “Support that meets the regional characteristics.” Along with individual and environmental elements, support from experts in the region was cited. Hence, it was concluded that the active participation of experts is essential for promoting activities in local communities, and that deepening relationship with older people has the potential to improve their quality of life.

Introduction

With the increasing number of older people in Japan (Cabinet Office, 2021), health promotion activities in local communities have become increasingly essential. Developing health-promotion programs needs to be considered from diverse perspectives (Ministry of Health, Labour and Welfare, 2019). For instance, to enhance the regional residents’ health and carry out effective health-promotion programs, the government recommends activities that consider the residents and the region's diverse cultures and the unison inclusive of generations and sectors (Ministry of Health, Labour and Welfare, 2019).

Activities that focus on the strengths of the regional residents are also recommended (WHO, 2015). Although nursing care focuses on the patients’ concerns, with increasing attention to patient-centered healthcare and the inner strength of patients, the patient problem-focused approach is not sufficient. To complement this approach, strengthening their health assets has attracted attention (Rotegård et al., 2010). Similarly, for health promotion in the community, health professionals must consider an asset-oriented approach instead of a community problem-focused approach (Sharpe et al., 2000). However, such activities have not yet been fully implemented. To revitalize health promotion in local communities using their strengths, it is crucial to first identify them.

Strength is a concept utilized when caring for older people (Shirasawa, 2005) that represents their positive aspects. However, strength has many different definitions. A report suggests it is a diverse concept with the strengths of a community to which public health nursing is provided, including the residents’ condition and the conditions surrounding them (Okamoto et al., 2019). However, the elements that comprise the strength of a community, including the conditions surrounding them, as perceived by the older people living in a local community, have not been studied. In health-promotion programs in the communities, it is preferable that the expert in the community deduces what the older people participating see as the ‘strengths’ of their communities and engage in regional nursing activities adhering to these perspectives. In Japan, with the increasing population aging, clarifying the strengths of the community perceived by older people can help nursing practice make use of the strengths.

This report aims to identify the elements of regional strengths perceived by older people living in local Japanese communities by reviewing the literature about the strengths of community-dwelling older people. Identifying such strengths is a significant primary key for health promotion in local communities in Japan's super-aging society.

Methods

In this report, regional strengths was defined as the physical, mental, and social elements that include positive factors possessed by individuals and the physical and environmental elements that surround them (Sakugawa et al., 2010). Local communities are characterized by the regional culture, customs, and physical geographic environment. Thus, the authors considered that the notion of a community may be perceived differently in Japan and overseas; hence, in this study, they searched solely for papers on Japanese regional residents.

The qualitative systematic review was conducted by using the internet edition of the Japan Medical Abstracts Society (Ichu-shi). The search period was until July 21, 2021. The following keywords were used: (1) “Older people (thesaurus)” and “Tsuyomi (free keywords)” (meaning “strengths” in Japanese) and “Chiiki (free keywords)” (meaning ‘community’ in Japanese), (2) “Older people” and “Strengths (free keywords)” (in English) and “Chiiki,” (3) “Older people” and “Tsuyomi” and “Chihou (free keywords)” (a synonym for Chiiki, meaning “Local area” in Japanese), and (4) “Strengths” (in English) and “Chiiki.”

The inclusion criteria were papers that extracted the regional strengths perceived by older people in Japan, written in Japanese with abstracts and that had undergone qualitative research, questionnaire surveys, and intervention evaluations. The published years were limited to those between 2000 and 2021. Exclusion criteria were papers whose research purpose and content did not include the strengths of the older people in the community, systematic review using secondary data analysis, commentary, papers of expert opinions or comments, and duplicate papers. As a result, 342 relevant papers were extracted, comprising 65 papers for (1), 33 papers for (2), 7 papers for (3), and 237 papers for (4).

To identify literature that signifies the factors relating to the strengths of older people in the community, the authors carefully read the abstracts of the 342 extracted papers and excluded literature whose purpose of research and matter did not focus on the strengths of older people in the community. The researchers also excluded reviews and redundant papers. As a result, 14 papers were extracted.

The authors assembled the author, year of publication, methods, participants, and main results of each report. Further, from the results, they extracted documents concerning regional strengths as perceived by older people. They then classified and organized them based on their meaning and matter similarities and summarized these elements.

Results

Overview of Research on the Strengths of Older People in the Community

Table 1 shows an overview of the articles analyzed. Diverse methods of research were used in the papers, including questionnaire survey (# 1, 5, and 11), observation method (# 2), the KJ method (affinity diagrams and brainstorming; # 3, 4, and 6), and ethnography (# 10). Older people, randomly extracted, were selected as the participants of the studies. These included couples, older people living alone who required nursing care, and widowers living alone. The participants included staff members (# 4) and public health nurses of community-based comprehensive support centers (# 10).

Table 1.

Summary of Included Reviews.

#1 Aniya et al., 2021 Methods: Questionnaire survey Participants: Older people living in a small region of about 4000 people The strength understood to be resources included “a convenient living environment(t),” “a reliable and safe town(n),” “school zones where it is easy to raise a child(n).” Many generations gathered in the “community center as a base for residents(o)” and did “abundant and lively activities(n).” The strength of social relationships realized by the older people were “diversity in connections(r)” and “rooted territorial connections(r).”

#2 Somiya & Matsushita, 2021 Methods: Observation method Participants: Two couples (two men and two women) and three nurses Nursing practice was based on these care plans, consisting of “maintenance and promotion of patients’ mental and physical health(l),” “collecting data on the patient or family's daily living conditions and thoughts(k),” “support tailored to the patient or family(k),” “care that supports the patient or family's satisfaction and thoughts(k),” “continuation and reinforcement of residents interactions(u),” “establishment of relationships with the patient or family(k),” and “alleviating the caregiving burden of the family caregiver(l).” Further support for the patients included “support for patient's comfort(k),” “support for decision making(j),” “cooperation and collaboration with other occupations(u),” “effective utilization of scarce resources(s)” and “reliable medical assistance(u).”

#3 Tada et al., 2020 Methods: Qualitative Integration method (KJ method) Participants: Six home-visit nursing users requiring nursing care 4 or 5 (average age 86 years) The emotional support of the older people who had lived while receiving care at home was a “confidence in survival(b),” including pride in hardwork(b), and experience of enduring adversity(b); the “connecting with surrounding people(r),” including family support(q), gratitude towards supporting people, and connections with people in the past and present(r); and the “current strength,” including current satisfaction and hope(g), what I can do now for those who support me(c), and attitude towards difficulties(b).

#4 Saito, 2020 Methods: Semi-structured interview (KJ method) Participants: Seven staffs of community-based comprehensive support centers For seamlessly operating the social spaces for the older people in depopulated areas, four insights are essential: (1) the community-based comprehensive support centers will explain the need for a social space to the community residents, (2) the life support coordinator will make the best use of the regional strength, and collaborate with supporters and existing organizations(o), (3) the community-based comprehensive support centers will understand problems through the management or support of social spaces(o), and (4) it will utilize the existing vacant spaces in difficult-to-move areas(o).

#5 Nakano, 2020 Methods: Questionnaire survey Participants: 1057 people who underwent a specific medical examination The common factor of the older people in the four types of community activities, including neighborhood association activities(p), seniors’ club activities(p), volunteer activities, and sports club activities, was the “number of people consulting with neighbors(r).”

#6 Zhang, 2019 Methods: Qualitative synthesis method (KJ method) Participants: Three community-dwelling senior couples living independently The couple's characteristics for continuing to live independently at home consisted of the following five characteristics: “do favorable activities and enjoy a satisfying life in good health(g),” “engage in free discussion and acquire the space each other to alleviate stress(d),” “gratitude towards husband for managing domestic affairs with warm-heartedness post compulsory retirement(e),” “devising ways to adapt to the various challenges of aging, such as physical, emotional, economical, and environmental changes(c),” and “focus on health promotion and the ability to provide delicate attention(a).”

#7 Okuchi et al., 2019 Methods: Qualitative inductive study Participants: Ten individuals participating in organized community events for the older people The strengths of older people for confidence included: “derived from past hardship(b),” “living healthy, independent life(f),” and “having raised a family and contributed to the community(q);” abilities included: “producing, storing, and processing rice and vegetables,” “managing and utilizing snow(m),” “maintaining and improving health(a)” and “self-actualization and social contributions(h);” desires included: “to continue living locally and independently(f),” “to pass away without burdening others(f),” and “to pass on local traditions and ties to the next generation(i);” natural environmental resources included: “residential property, arable lands, and mountain forest assets(m),” and “the nature and culture bounty of a snowy region(m);” social ties included: “support from familial and community interactions(q)” and “popularity arising from engaging with the local community as a senior citizen(r);” opportunities included: “close relationships with neighbors(r),” “gathering for health promotion events organized by the local community(p),” and “gatherings for volunteering and hobbies(p).”

#8 Ohashi & Katsura, 2018 Methods: A before-after study using one group Participants: Thirty-two women living independently The authors conducted programs for examining strengths and clarifying self-value and self-goals. The program intervention significantly increased the total scores of the sense of worth in living(g), and the average scores of the sense of fulfillment of life(g), self-actualization, and motivation(h) at the follow-up than those at the baseline.

#9 Shimasaki et al., 2017 Methods: Qualitative inductive method Participants: Five older people (75 years old and over) who have been participating in the project for supporting the long-term care prevention activity for two years or more The strength of the older people who participate in the project were: “I have a feeling for the future way of life based on my current condition and feelings,” “I have a strong daily life and lead a rich life(g),” “I feel good for my body and maintain and improve my physical function(a),” “I am learning from each other and gaining wisdom”, “I am finding a new self(i),” “I have a relationship where I care and interact(r),” “I have the pleasure of going to places with friends and doing activities,” “I have motivation to do my best,” “I am gaining confidence,” “I have a person who supports me,” and “I have a place where I am active and proud in my living area(o).”

#10 Matsutani & Hara, 2015 Methods: Ethnography Participants: Nine older people aged 75 or over and a public health nurse The older people living in the hilly and mountain area “recognized their age-related and the community changes(c)” in their daily lives. They found “ways for coping well with aging(f)” and “created their own roles in the community(i).” They made efforts to “continuously present themselves as members of the community(r).” Aspect of “what support the aging persons(c)” and the “effort to coordinate aging self with changing community(c)” interacted with each other and promoted “their effort to continuously present themselves as members of the community.”

#11 Nakatsui et al., 2015 Methods: Questionnaire survey Participants: 28 senior citizens This study suggested the necessity of social support considering the regional characteristics centered on interaction between residents(p) to maintain the health-related QOL (Physical Component Summary and Mental Component Summary) of senior citizens living in semi-mountainous areas.

#12 Taba et al., 2014 Methods: Structures face-to-face interviews Participants: 13 older people living alone and requiring long-term care The structures of strengths for the older people who require long-term care to continue living by themselves included “strength to form and maintain relationships wherein independence or selfhood can be exhibited(e),” “strength to form new relationships(e),” “strength to accept suggestions from others and attempt new things(e),” and “strength to engage in solving problems to live with the need for long-term care(d).”

#13 Tadaka et al., 2013 Methods: Qualitative induction research Participants: 20 older men living alone (70–93 years of age) in two districts The theme of strength related to participants’ social isolation was “autonomy,” such as “I want to do my best I can,” and the theme of weakness was “loneliness” in both districts. However, “socializing among neighbors and community(r)” differed between the two areas: suburban farm district showed “strong membership and kinship in the community” and urban high-rise apartments district showed “weak membership and kinship in the community.”

#14 Sannomiya et al., 2011 Methods: Interview method Participants: 30 older people living in the mountainous villages The basic requirements for developing a welfare community that contributes to improving the QOL of older people living in mountainous areas are “preventive measures for decreasing walking ability based on health conditions(l),” “acquisition of inexpensive and highly convenient means of transportation(t),” “providing a diverse opportunity to go out(u)” and “collaboration with households with children(q).”

Note. Items indicate authors and year of publication, methods, participants, and main results of each report. The italic parts show the concepts that make up the subcategory (a) to (u).

Individual Elements Comprising the Regional Strengths as Perceived by Older People

The individual elements that comprise a regional strength as perceived by the older residents consisted of three categories: “Actions or behaviors underpinned by experience,” “Continuing to live with positivity and vigor,” and “Extensive support for the subject and their family.” Actions or behaviors underpinned by experience were further comprised of the following subcategories: “Activities to maintain health (a),” “The experience of having overcome difficulties (b),” “Adaptation to old age (c),” and “Problem-solving ability (d).” Continuing to live with positivity and vigor constituted of the following subcategories: “Refinement of interpersonal relations (e),” “Independent living (f),” “Things to be considered meaningful in daily life (g),” “Creating relational roles to play (h),” and “Things to pass on to the next generation (i).” Extensive support for the subject and their family consisted of the following subcategories: “Support for decision-making (j),” “Support for building sympathetic relations with the subject (k),” and “Support for promoting the health of the subject and their family (l).”

Environmental Elements of the Regional Strengths as Perceived by Older People

The environmental elements contributing to the regional strengths as perceived by the older residents comprised three categories: “A comfortable environment,” “Maintaining intimate and friendly interpersonal relations,” and “Support that meets the regional characteristics.” A comfortable environment constituted: “The regionally unique general environment (m),” “A safe and secure environment (n),” and “A communal space for sharing activities in the region (o).” Maintaining intimate and friendly interpersonal relations comprised of: “Events and activities in the region (p),” “Kinship with family, acquaintances, and neighbors (q),” and “Bonds among neighbors (r).” Support that meets the regional characteristics comprised: “Effective use of finite medical resources (s),” “A high degree of convenience (t),” and “Maximum use of regional resources (u).”

Discussion

Elements of the Regional Strengths as Perceived by the Older People

Elements of the regional strengths perceived by the older people in the local community can be divided into individual and surrounding environmental elements.

For the individual elements, their relationships with other people fostered in their daily lives were cited. In other words, knowledge and behaviors acquired through daily living and living life with a sense of being were essential elements. Regarding the strengths possessed by older people, a range of elements has been cited, including courage, gratitude, hope, humor, kindness, perseverance, and spirituality (Waterworth et al., 2019). Although these elements are not cited in the results of this study, they may have formed the foundations of older people's lives. The primary measures of strengths among older people themselves consist of three interlinked domains of analysis: the individual, the interactional, and the contextual (Janssen et al., 2011). The individual domain includes older people's beliefs, efforts, and capacity to understand themselves. The interactional domain includes reinforcing relationships by cooperating and interacting with others to achieve personal goals. The contextual domain refers to the accessibility of care services, the availability of material resources, and the strength of social policy. In the results of this study, “Problem-solving ability,” “Refinement of interpersonal relations,” and “Support for building sympathetic relations with the subject” are cited as sub-categories. This aligns with the report by Janssen et al. (2011). Regional experts building trust with older people and their families and offering them extensive support were also essential elements.

One environmental element was that their environment in the local community was comfortable for living. This implies that the sense of security brought about by living in the region's natural environment or having a communal place for sharing activities was considered a strength. This aligns with an earlier report that cited the availability of material resources and the resulting strength of social policy as a strength of a local community (Janssen et al., 2011). Maintaining intimate and friendly interpersonal relations was also considered a strength. Maintaining friendly relations with other people has been noted to prevent older people from becoming isolated (Yajima & Yaniwa, 2018). Hence, the ability to prevent isolation through community activities, connecting with regional residents, and interacting with family and relatives are also crucial components of these strengths. Support that meets regional characteristics was also cited and aligned with a report that cited regionally-based care as an example of regional strength (Wong et al., 2019). It has been observed that accessibility of care services, availability of social resources, and support from the regional society, family, and experts, lead to enhancing strengths and resilience (Van Kessel, 2013). This “ripple effect” on strength was also inferred from the results of this study.

“Things to pass on to the next generation,” “Support for decision-making,” “Events and activities in the region,” and “Maximum use of regional resources” match the regional strengths wherein public health nursing is involved, such as passing on cultural values and beliefs in regional settings, decision-making, organizational driving force, district organizations, and the ability to tap and utilize resources (Okamoto et al., 2019). Therefore, we believe that it is one of the regional strengths that professionals such as community nurses connect with older people and cooperate in activities in the community and utilization of social resources.

Practice Towards Promoting Activities to be Implemented in Regional Communities

Along with individual and environmental elements, support from experts in the region was cited as a regional strength as perceived by older people. Therefore, the participation of experts is essential in promoting activities carried out in local communities in Japan's super-aging society. Deepening relationship with older people has the potential to improve their quality of life.

Enhancing the regional strengths can allow older people to effectively cope with the losses they suffer that come with aging (Janssen et al., 2012) and enhance their subjective well-being (Viglund et al., 2014). Since geographic and physical environments vary depending on the region, it is crucial to focus on local resources that the local community can prepare and implement with the residents.

Limitations and Future Challenges

Health assets, including strengths in the local communities, have received worldwide attention, and a systematic review has been published (Van Bortel et al., 2019). This report is significant as an example of research in Japan. The findings of this study can help policymakers and providers of community health services supplement the missing methods of community problem-focused approaches.

There are several limitations to this report. First, it exhibits knowledge and information solely based on the literature on the regional strengths of older people living in local Japanese communities, providing a relatively limited viewpoint. Regional communities have distinct regular and physical environmental conditions, which cannot always be generalized. Second, the definition of “strengths” has diverse aspects, and the results may vary depending on their definition. However, this study is significant because the promotion of health and well-being in local communities is considered to allow older people to live comfortably and authentically in society. Lastly, in this report, the sole user database was “Ichu-shi,” which covers medicine, nursing, dentistry, pharmacy, and veterinary medicine, because the primary aim is centered on nursing. Hence, papers cited only in CiNii, which includes domestic academic journals, may have been overlooked.

Since the literature published in Japanese journals was used, the findings of this study were limited to the utilized target area. Further research focusing on diverse older adult populations is necessary to utilize the findings. Furthermore studies must consider the definition of strengths, its evaluation methods, the provision of nursing support that enhances the strengths of older people in diverse local communities, and the accumulation of research results.

Conclusion

In this study, the authors reviewed the literature on the regional strengths of older people living in local Japanese communities. As the regional strengths as perceived by older people, three categories were cited for individual elements: “Actions or behaviors underpinned by experience,” “Continuing to live with positivity and vigor,” and “Extensive support for the subject and their family.” Three categories were cited for surrounding environmental elements: “A comfortable environment,” “Maintaining intimate and friendly interpersonal relations,” and “Support that meets the regional characteristics.” Along with individual and environmental elements, support from experts in the region was cited. Hence, it was concluded that the active participation of experts is essential for promoting activities in local communities, and that deepening relationship with older people has the potential to improve their quality of life.