Age-Friendly Environment and Community-Based Social Innovation in Japan: A Mixed-Method Study

Abstract

Background and Objectives

While governments are building age-friendly environments, community-based social innovation (CBSI) provides opportunities for older community residents to interact. Common CBSIs in Japan are in the form of group exercise activities or social–cultural activities, such as reading, writing, poetry, chorus, calligraphy, card game, knitting, planting trees, and cooking. In this study, an age-friendly environment in Japan was assessed quantitatively and qualitatively through the perceptions of community residents and their interaction with the environment.

Research Design and Methods

A cross-sectional survey of 243 participants and multiple in-depth interviews were carried out. A quantitative study applied the World Health Organization (WHO) framework of 20 age-friendly environmental factors with analysis applying a structural equation model. A qualitative study applied focus group meetings and in-depth interviews to conduct a thematic analysis of Japanese community residents’ activities according to the WHO scope of CBSI for healthy aging.

Results

This age-friendly environment in Japan has provided pathways for the older people to sustain their social network, which promotes civic participation and engagement in peer group activities leading to active aging. CBSIs are the factors that lead to an age-friendly environment resulting in a sustainable quality of life.

Discussion and Implications

It is important to sustain CBSIs in the era of coronavirus disease 2019 pandemic as those are the paths leading to healthy aging communities and quality of older residents’ life. The lessons learned about how physical environment and social participation result in healthy, active quality of life for older adults in Japan may be applicable to other contexts around the world.

Aging in place, COVID-19, Public health, Social gerontology, Social policy

Population aging is a common global phenomenon in the twenty-first century (World Health Organization [WHO], 2020a). Since the twentieth century, Japan has been experiencing demographic changes leading to a super aging society (Luk, 2020). In 2019, it was home to 35.89 million people older than 65 years (Statistics Bureau, 2020). More than one in four Japanese are older persons, constituting 28.4% of the total population, the highest in the world (Statistics Bureau, 2020). Meanwhile, the life expectancy of Japanese citizens became 81.41 years for males and 87.45 years for females in 2019, also the highest in the world (Statistics Bureau, 2020). This has influenced not only the epidemiology of diseases but also the social policy of the country by investing more in social welfare and healthy aging.

By 2030, the retirement age will be raised from 65 to 70 in Japan in order to stabilize social security revenue (Luk, 2020). In this setting, the potential of the older population constitutes a powerful basis for the sustainable development of the country. Such potential can be achieved through addressing the health, rights, and well-being of older adults. Healthy aging, according to the WHO, means that functional ability is maintained according to what older persons value (WHO, 2020a). Because people’s values are contextual, age-friendly environments (AFEs) in which older persons can maximize their active aging, productivity, civic participation, and quality of life will be diverse.

Most older people wish to live in the home and community where they grew up safely, independently, and comfortably, regardless of age, income, or functional ability level—a phenomenon known as “aging in place” (Vanleerberghe et al., 2017). Alongside their home, the immediate neighborhood, public spaces, and supporting activities are important to cope with everyday life and social participation. Without a supportive environment, retreat from public life can lead to fading relationships and social isolation (Fu et al., 2017; Stafford, 2018). This is certainly more serious for people with limited mobility. Without the ability to commute and accessibility to information and services, the home can become a place of isolation. This is more of an issue in resource-poor places where demographic changes lead to a declining population. Japan national statistics reports from 2019 showed that one in two households has a person aged 65 years and older, while a third of households comprise an old-age couple only (Statistics Bureau, 2020). This highlights how urgent it is for communities to be age-friendly and the importance for every city to consider the future investment to develop such AFEs (Tiraphat et al., 2020; WHO, 2020b).

Scholars have regarded an AFE as a theoretical policy framework to build communities via the national government (Buffel & Handler, 2018; WHO, 2015). Such a point of view may hinder initiatives in many poor and developing countries when considering an investment in care services. Many researchers adopt an environmental gerontology perspective while others approach it from a social gerontology perspective (Buffel & Handler, 2018; Buffel et al., 2014; WHO, 2020b). The WHO definition of healthy aging refers to the creation of environments and opportunities that enable people to be and do what they value throughout their lives (WHO, 2020a). When the values are considered, this definition is very contextual (Aung et al., 2020). Therefore, this study sought to look beyond a quantitative checklist and assessment, in terms of how older persons in Japan interact with their environment, and the effects on their health, well-being, social participation, and quality of life.

Recently, the WHO Centre for Health Development, Kobe Centre, reported on community-based social innovation (CBSI) in 10 middle- and high-income countries (Ghiga et al., 2018). This was the first report and it did not include Japan. CBSIs are “initiatives that seek to empower older people to improve their self-efficacy in caring for themselves and their peers, maintain their well-being, and promote social cohesion and inclusiveness” (Ghiga et al., 2018, 2020; WHO, 2018). Alternatively, CBSIs are the contextual models that explore how an AFE and older persons interact leading to healthy aging. Many such initiatives have been implemented in Japan although they have not been named as CBSIs (Saito et al., 2019).

Since 2017, Japan has been investing to build a new system where medical care, nursing care, preventive care, and livelihood support are integrally provided in the communities where older persons live. The system is called the Community-based Integrated Care System (Ministry of Health, 2017). This system aims to enable older people to live for the rest of their lives in their own ways in environments that are familiar to them, even if they become heavily in need of long-term care. Creating an AFE has been a policy for many cities across the country. Therefore, a study located in Japan that investigates AFE and CBSI is ideal as a contribution to gerontology research.

While governments are building AFEs, CBSIs, such as group exercise, and social and cultural activities, such as reading, writing, and cooking, provide opportunities for interaction. If AFE is the infrastructure for healthy aging, CBSI in each context may reveal the mechanism of social interaction leading to the improved quality of life for older adults (Ghiga et al., 2020). Therefore, in this study, an AFE in Japan was assessed quantitatively and qualitatively through the perceptions of community residents and their interaction with the environment.

Method

The present study applied a mixed methodology. The explanatory sequential design (QUAN → QUAL), a two-phase research design, was used in this study (DeCuir-Gunby & Schutz, 2016). A quantitative study investigated how older adults perceived an AFE in their communities using structured questionnaires. A qualitative study explored the importance of the neighborhood in the lives of older people in terms of their civic participation and health promotion in the scope of CBSI (Stafford, 2018).

Quantitative Method

A mail survey applying self-administered questionnaires was conducted recruiting participants from different parts of Japan: Sapporo, Hokkaido region (northern part); Kobe, Kansai region (western part); Oita and Miyazaki, Kyushu region (southern part); Hiroshima, Chugoku region (southwestern part); and Tokyo, Kanto region (eastern part). The research instrument, a printed questionnaire, was piloted to ensure the survey template was user-friendly for the older respondents. Researchers distributed the questionnaires to the older participants through the primary health care centers or community groups. An informed consent form, the questionnaire, a ballpoint pen, and a returning envelope were enclosed in an envelope and distributed to the participants. Three hundred envelopes were distributed.

A total of 243 (81%) participants consented, answered the survey, and returned their responses to Juntendo University by postal mails. Quantitative data collection was carried out in 2019. Field observations of various community-based activities were conducted until January 2021, alongside interpretation of the survey results. In-depth and focus group interviews were started in 2019. During the emergency declaration for control of the coronavirus disease 2019 (COVID-19) pandemic, the interviews were stopped in 2020. The last interviews applied Zoom video conferencing.

The research protocol was approved by the ethical review committee. Based on WHO-recommended measurement, 20 age-friendliness indicators were transculturally translated into Japanese and piloted (WHO, 2015; Figure 1). From these 20 questions, two questions directly ask about community-based social activities: (a) whether you participate in group physical activities in your leisure time and (b) whether you have participated in sociocultural activities at your own discretion at least once in the last week. In this study, these questions are considered as CBSI indicators.

Figure 1.

Twenty factors of the age-friendly environment. Notes: Diamonds are median values. By comparing median values, gaps between two genders can be identified.

Cohen’s social network index was applied to measure the social network diversity belonging to the older person. It was calculated as the number of social roles in which the respondent has regular contact, at least once every 2 weeks, with people in 12 types of social relations such as a spouse, parents, children, children-in-law, close relatives, close friends, religious members (such as church or temple), classmates, teachers and students in adult education, coworkers or colleagues (employee or employer), neighbors, volunteer networks, and other organizations (social clubs, recreational groups, trade unions, commercial groups, professional organizations, and clubs for older people; Cohen et al., 1997) Single-item measurement tools for active aging (Ronzi et al., 2018) and for quality of life perceived value (Siebens et al., 2015) were used.

The questionnaires were made to be age-friendly in terms of being short, visible, and comprehensible. STATA version 16.1 Special Edition (StataCorp, 2019) was applied for data analysis. Descriptive analysis elaborated the AFE which the senior citizens are currently experiencing in Japan and identified gender inequalities. Multivariate analysis applied structural equation modeling in STATA (Gan, 2019). The paths to quality of life through participation in CBSI, in the presence of age-friendly indicators, were sought. Direct and indirect relations were identified to construct the conceptual model. The chi-square goodness of fit test, which is sensitive to the sample, was applied to check the overall model fit. The comparative fit index, which is not sensitive to the sample, was also applied to check the model fitness.

Qualitative Method

The qualitative study applied in-depth interviews and focus groups. In-depth interviews were carried out with the volunteer exercise group trainers, primary health care providers, health cooperative managers, and members of “Kizuna saloons” (bonding saloons) and ground golf clubs. Primary data collected and analyzed for the study were gathered from interviews with older participants in Tokyo and Yamagata cities using the snowball sampling technique. A total of 26 in-depth interviews were conducted with participants who were community residents aged 65–87 years. Moreover, 10 focus group interviews were conducted with group exercise trainers, saloon coordinators, and primary health care providers. Each focus group comprised four to five participants. Two aims were to classify the typology, development, and delivery of CBSI in the Japanese communities and to understand the relationship between these activities to active aging and quality of life.

The qualitative analysis applied narrative analysis to construct meaning from the stories of the participants and thematic analysis of interview data, photographs, videos, and notes from the participatory observation. Quotes were translated and written in English for readability while originality was double-checked to retain.

Data integration was applied throughout the research. In relation to collecting the data, quantitative data collection was carried out before qualitative data collection. Interviews explored the details of the CBSI activities. The findings were integrated into the survey results. During the analysis phase, structural equation modeling was guided by the interview results.

Results

Quantitative Findings

Male and female participants were almost equal (male 54%; female 46%). The median age of the whole sample was 74 years. All were community residents. Two thirds of the participants were married and living as a couple (68%). Most of the participants were educated higher than high school education (Table 1).

Table 1.

Characteristics of the Participants in the Survey (N = 243)

	Male (n = 110)				Female (n = 130)
Variables	n	%	Mean	SD	n	%	Mean	SD
Education
High school and higher education	92	82.8			103	79.2
Primary, secondary, and other	19	17.1			27	20.8
Religion
No religion	34	34.3			43	37.4
Buddhist	65	65.7			67	58.3
Christian	0	0			5	4.4
Residence
Tokyo	13	11.7			29	22.3
Hokkaido	35	31.5			28	21.5
Kansai	21	18.9			25	19.2
Kyushu	42	37.8			48	36.9
Marital status
Married	90	83.3			71	55.5
Spouse passed away	9	8.3			47	36.7
Divorcee	2	1.9			7	5.5
Separated	1	0.9			0	0
Cohabitation	5	4.7			0	0
Single	1	0.9			3	2.3
Age			73.7	6.3			75.0	6.9
Active aging (1–10 scale)a			5.6	2.4			5.7	2.0
Social network index (0–12 score)a			4.7	1.5			4.5	1.7
Quality of life (1–7 scale)a			4.2	1.1			4.4	1.1

Note: Three participants did not answer gender.

^aMultiple analysis of variance (MANOVA) p = .39.

Figure 1 shows how participants perceived how age-friendly their communities are.

The overall lowest score was the opportunity for paid employment. Gender inequality was observed for some factors. Volunteer activity was more frequent among females while internet access was higher for males. Female participants reported more opportunities to join community group exercise (CBSI1) than males, while both genders reported the same level of participation in sociocultural activities, with a low rating of 1 of 4. The female participants perceived respect and social inclusiveness less than the male participants, as well as revealing less satisfaction with public transportation and private parking.

Direct and indirect pathways were identified (Table 2). Quality of life is directly influenced by active aging: β 0.13 (0.07–0.20), p < .001 and neighborhood safety and income security. Active aging is directly influenced by participation in community group exercise (CBSI1) and social and cultural activities in “Kizuna bonding saloons” (CBSI2) and feeling safe in the neighborhood. Participation in CBSI1 and CBSI2 was found to have a significant direct relationship with the social network. Social network is directly influenced by volunteer activity, paid employment, and internet use (Figure 2; Table 3).

Table 2.

Structural Equation Modeling Paths to Quality of Life Among Older Community Residents Resulting From Age-Friendly Environment Through CBSI

Dependent variables	Path	Independent variables	β	CI	p
Quality of life	Direct	Active aging	0.13	0.07–0.19	<.001
		Financial security	0.26	0.15–0.37	<.001
		Safe neighborhood	0.31	0.15–0.48	.01
	Indirect	Community exercise (CBSI1)	0.07	0.02–0.11	.002
		Social and cultural activity (CBSI2)	0.06	0.02–0.10	.004
Active aging	Direct	Community exercise (CBSI1)	0.53	0.31–0.74	<.001
		Social and cultural activity (CBSI2 bonding saloons)	0.47	0.23–0.69	<.001
Social network diversity	Direct	Volunteer activity	0.41	0.26–0.56	<.001
		Paid employment	0.20	0.04–0.35	.016
		Access to internet at home	0.21	0.09–0.33	.001

Notes: CBSI = community-based social innovation; CI = confidence interval. p = .119; χ ² = 19.148; comparative fit index = 0.973.

Table 3.

Examples of Program Content in Community Based Social Innovation (CBSI) for Healthy Aging in Japan

CBSI1: Community-based group exercise	CBSI2: Community-based social and cultural group activities
1. Group exercise for preventing frailty and long-term care needa 2. Tai chi 3. Ground golf 4. Gate ball 5. Group walking	1. Chorus group 2. Poetry (Haiku) group 3. Handicraft group: flowers, bamboo 4. Cooking group 5. Majong card game 6. Paper game (Origami) group 7. Reading aloud (Roudoku) group 8. Harmonic group 9. Calligraphy (Japanese characters) 10. Pen calligraphy 11. Postcard painting group 12. Knitting group 13. Planting trees group

Note: CBSI = community-based social innovation.

^aIn Japanese, it is called Kaigoyobou Taisou; a well-known example is Koroban Taisou.

Figure 2.

Conceptual model showing paths from age-friendly environment to CBSIs, resultant active aging and quality of life. SEM = structural equation modeling; CBSI = community-based social innovation. Model fitness: p = .119; χ ² = 19.148; comparative fit index = 0.973.

Indirect pathways: Participation in community group exercise and social–cultural activities contributed to the quality of life in the indirect pathways. In brief, it can be seen that CBSIs are indirect contributors to the older persons’ quality of life and direct contributors to active aging (Table 2; Figure 2).

Qualitative Findings

Many community-based social activities take place in what in Japanese is called a “Kizuna saloon.” Some of the best examples are given in Table 3. The in-depth interviews about Kizuna saloons showed how the environment facilitates social interaction among older adults. The saloons are named after flowers such as the Himawari (Sunflower) saloon and the Tanpopo (Dandelion) saloon. Community-based social activities require spaces for older people. Kizuna saloons are situated in public places such as an old primary health care clinic or an elementary school. One of the places was a donated house owned by a writer whose name was Ohara San. When he passed away, his house was given to the public for the older community residents. It became a venue for the older people living in the community to gather and participate in many kinds of social activities.

CBSI1: Community Group Exercise Clubs

Exercises clubs are a very good example of CBSI that promotes an AFE. These exercise clubs have existed since the early 2000s. Participants from different types of exercise clubs were interviewed. Some of the similarities among them include being community-based and aiming to prevent frailty and falling (Table 3). The main difference relates to the trainer models. The most common one is the group exercise led by a community volunteer trainer with a television or projector; the second one is the professional trainer-led club; and the third one is the volunteer trainer-led activity using just a cassette for playing music.

The idea was originally brought to the community by the health cooperative executive who coordinated academics from universities to launch community group exercises for the prevention of long-term care need and frailty among the older adults living in the communities. Following this, a program of training older community residents was introduced, who would later become volunteer trainers to lead regular community exercise clubs. Notably, the female participants far outnumber the males in exercise clubs.

The delivery of such a program into the community is very important for its sustainability. A professional trainer is very good, but it is not possible to have a professional trainer for each regular activity. Therefore, the provider may follow a model with a community-based volunteer trainer. While the program is not free, the cost is very low—$1 for tea and a snack after physical exercise—and affordable for the members.

Providers’ messages are simply relayed to the older adults through a printed brochure. Effective health communication messages are included, such as Falling is the most common cause for long-term care need: let’s prevent it and stay independent. Join the exercise program. Incentives are provided to older adults. Participants can get 1 point equivalent to 50 Yen and volunteers can get 5 points for an event. These points can be used to purchase products at the cooperative shops in the municipality. Moreover, physicians encourage older adults to join such exercise programs during their annual health checkup visit. Long-term social connection, physical fitness, autonomy, and fun are the factors that retain the older adults in the community exercise clubs.

One participant said: “It was really fun to perform exercise with friends together. I felt that my body is really different, easy to move, more stable and I can sense well-being.”

Furthermore, it was discovered that older adults who are socially active invited their friends to join the activity. Older adults who talk less with people found out about the event in the local newspapers.

It is a regular meeting with my friends, neighbors and peers. We can exchange information. We can talk to each other. We can ask how each person is doing. We know if someone is absent from the exercise club and then we start to investigate if she or he is well or sick. At this age we need to watch out for each other. In Japanese culture this is called “mimamori” (being a good, watchful neighbor).

CBSI2: “Kizuna Saloons” (Bonding Saloons)

Interestingly, the exercise programs are sandwiched in between other social–cultural activities. Some older adults do not really like to exercise. However, because of the social connection and opportunity to meet other people, they joined the program. Some prefer the nonexercise activities that consist of diverse social and cultural activities. “I remember the tea-time after the exercise. We are always excited to have a tea party after two rounds of 45 minutes exercises” (Figure 3).

Figure 3.

Older people participating in the activities of community based social innovation (CBSI) for healthy ageing: Participants doing care prevention group exercise in the communities linked with Zoom (left) and having conversation over tea and snack (right).

The narrative from an interview of a gentleman and three women about their experiences and memory of the Kizuna bonding saloons is remarkable.

I still remember the smell from the kitchen where my friends were cooking lunch. Those days were the best of my memory. Friends had barbecue parties in the garden. Some played music. It was like an outdoor concert. Kids and middle-aged people sometimes joined the activity. Mobile shops selling vegetables and local products from some provinces frequently came there. Even readily cooked food was available for the older people.

A 77-year-old volunteer explained the story of a “modern Japanese poetry” poem club there. She taught older community residents how to write a Japanese “Haiku” short poem. Earlier in the day, people at the gathering aged 80–85 did not really talk to each other. The saloon was so quiet. Then they learned how to write poems. Everyone wrote a poem to reflect their life story. The stories were very diverse such as experiences in World War II or living in the Philippines. During the interview, the participants recalled and talked to each other about the various good poems that were written.

“A kind and watchful neighborhood is a social basic for healthy aging,” one respondent said referring to her story about being helped by two of her neighbor’s children when she was sick. When the older person is becoming frail, the kind and watchful care of a neighbor is truly essential. In Japanese culture, this is called “mimamori.” A kind neighbor is precious like a guardian angel. Someone who asks how are you every morning and investigates curiously if you are not seen as usual is a social need for older people, especially for those who live alone. Friends and neighbors can provide you with information about community care services. Care service staff will be at your door when volunteers and neighbors connect the service providers to those who are in need. When an older person cannot go shopping, the community service can provide shopping delivery. These are real examples of a caring community and features of an AFE in Japan.

Ground Golf Players in Yamagata

Ground golf originated as a community-developed event that has systematically progressed to have well-established association, membership, and tournaments. Ground golf players in Yamagata prefecture highlighted the importance of public space and social contacts.

Walking on the grass lawn cured pain in my knee and back.

It is the fun of sharing those moments with my friends that keeps me playing ground golf.

Transportation, affordability, and public space are the basic requirements for participating in ground golf. Feelings of fun and well-being and being connected with friends are the drivers to start and keep participating in ground golf.

The themes that emerged from the interviews relating to “social relations,” “friends,” and “fun” keep the older persons engaged in the CBSIs as well as an environment that promotes “autonomy,” “security,” and “respect.” “Volunteerism,” “public spaces,” and “community-developed ideas and models” sustain the health promotion activities. The participants’ narratives reveal how functional ability and the environment interact leading to active and healthy aging.

Discussion

For active aging to take place, older persons require an AFE (Miura, 2019). Attributes of such an environment can be measured through the community residents’ perceived value as indicators (Figure 1). It is the infrastructure of the physical and social environment that favors older persons’ civic participation, social connection, health, and quality of life (Buffel & Handler, 2018). In this study, a mixed-method approach was used because both the breadth and depth of older Japanese persons’ experiences with CBSI within age-friendly communities were to be explored. This allowed access to a considerable number of participants through surveys in different regions and the conducting of in-depth interviews with key informants to explain the details of significant findings. These integrated findings were expected to provide a nuanced interpretation of the participants’ experiences as real-life indicators of the AFE (DeCuir-Gunby & Schutz, 2016).

A person’s social network usually declines as they grow older (Wilmoth & Silverstein, 2017). In the structural equation modeling, it was found that the opportunity for volunteer work, paid employment, and internet access can enrich a person’s social network diversity (Table 2). There is a gender gap. The female participants had less internet access at home as well as lower opportunity for paid employment. However, the opportunity for volunteering was higher among females (Figure 1). In different ways, these environmental attributes represent an investment in the AFE that maintains the social networks of both genders. When the quantitative findings and qualitative findings are integrated, the social network of the older person is reciprocally related to active aging (Figure 2). CBSIs serve as opportunities toward active aging and quality of life for older people through social inclusion, civic participation, and functional capacity in the presence of AFE.

Quantitative findings showed that CBSIs offered the paths to active aging for the community residents resulting in improved quality of life (Table 3). Interpreting the quotes that were reported in the result clarifies how CBSIs lead to healthy aging communities. CBSI1 community exercise groups are good examples of collective action for health promotion and social participation. Participants described their sense of independence. Moreover, meetings and gatherings after exercise clubs offer the opportunity to maintain social connection among older community residents.

CBSI2 Kizuna bonding saloons are based on hobbies and serve as the venue for shared values (Table 3). They comprised diverse activities that served beyond the purpose of health. The Kizuna saloons enhanced the older people’s autonomy, enabling them to enjoy their lives based on their own interests. Furthermore, the older people can volunteer as a leader, organizer, or messenger for the activities and events. The ability to help others gives life meaning and motivates the Japanese older people. Such social motivation leads to sustainable and regular participation in the CBSIs (1 and 2) whether it be for physical fitness or hobbies. What older participants described their memories about CBSI2 were not only peer group activities but also intergenerational activities in their communities. CBSI2 also has an intergenerational bonding effect. Quotes in narrative findings indicated that social network and active aging are reciprocal (Figure 2). In summary, the qualitative findings in this study revealed how CBSIs enriched the older person’s social network, autonomy, civic participation, and collective action for health promotion.

Recent cohort studies reported that participants of community-based group exercise activities like CBSI1 were less likely to get frail, and participants of social and cultural group activities at bonding saloons like CBSI2 were less likely to get dementia in the year-long follow-up (Ide et al., 2020; Saito et al., 2019). Therefore, CBSIs are the bio, psycho, and social paths to active aging and improved quality of life of the older community residents (Tables 2 and 3). In the present study, these activities were subsequently explored qualitatively.

Interviews carried out in the community of Tokyo provided real-life evidence of how an age-friendly community contributed to older persons’ social participation, health promotion, and quality of life. Similar themes emerged from interviews of grand golf players in a city outside Tokyo as those from community-developed activities in Tokyo. In fact, some of the activities were initiated by the participants themselves. Their contacts were invited to join the activity. Volunteerism, collaboration, and being coordinated in the primary health care network have become regular events. Good memories of fun, feelings of well-being, and connection with friends as a result of this participation lead to a socially driven motivation to sustain CBSI.

After all, community-based activities require public spaces, a safe neighborhood, a walkable environment, and affordable and age-friendly public transportation for the older person (Figure 1). Trains and bicycles were the most common ways that the participants commuted to the venue of group exercise in the study setting. Furthermore, neighborhood safety is a significant path to the quality of community residents’ life (Table 2). It is cohesive with qualitative findings that participants reported how their neighbors looked after the old people, referring to “mimamori” in Japanese culture. While care service is available, the neighbors help to provide information and communication. Conclusively, qualitative and quantitative findings are convergent upon the importance of safe and caring neighborhood to construct healthy aging communities. It is a challenge to Japanese communities how to sustain such a culture amidst the declining population.

Implication for Health System and Delivery of CBSI

The WHO Centre for Health Development (WHO Kobe Centre), reported on CBSI for healthy aging in 10 middle- and high-income countries across the world. So far, CBSI has never been reported on in Japan. In-depth interviews following the quantitative result investigated the details of CBSI of diverse activities.

The WHO has classified CBSIs into “user-driven,” “state-driven,” and “adaptive” types (Ghiga et al., 2018; WHO, 2018). Typologically, CBSIs in Japan are “user-driven” or “adaptive” types and are integrated into the health and social care system. Beneficiaries are active in the management and development of CBSI.

When CBSI is operating a large number of different activities, a large number of beneficiaries exist within a small/medium geographical scale. A high level of community empowerment in this user-driven adaptive model of CBSI can be seen. Therefore, CBSIs in Japan are scoring high (Ghiga et al., 2020). Their scope is diverse, as is the programs’ content. Health cooperatives are key players in the initiation of autonomy-favored health service delivery. The findings in the current study reveal that community empowerment was very systematically developed through the coordination of community residents, the municipality, and national policy.

CBSIs initiated by health cooperatives in the last two decades stem from the community and represent an AFE. Two types of CBSI were learned about: (a) an activity that originated as a community-developed idea and (b) a community-based idea (Naidoo & Wills, 2016). Community-developed ideas target factors beyond health and are mostly sustained within Kizuna saloons, such as poetry clubs, chorus groups, paper game groups, or flower growing clubs. Importantly, people brought the ideas which they sought to develop empowering them to introduce such activities. Community-based ideas are usually brought by the service provider and are implemented at the community level. These mainly target health, such as functional training exercises to prevent frailty and long-term care need, fitness clubs, or an advanced community gym. Such activities require initial training of techniques to practice and relay to the members (Figure 3).

The delivery of health services or health promotion services varies across different contexts. According to Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty (2011) by 2019 Nobel Prize-winning economists Abhijit Banerjee and Esther Duflo, there are three types of delivery: (a) the free-of-charge model, (b) the flat low-rate shared model, and (c) the paid business model (Banerjee et al., 2011). The one applied in Japanese communities refers to a customer-driven private business model. Most program providers believe that private outlets or providers can sustain products such as DVDs or books though the existing logistic services with the consumers paying the price. The majority of health care and welfare services are covered in health and long-term care insurance. Therefore, policymakers can shape the intervention and health promotion by expanding the insured services.

However, CBSIs that are usually health promotion activities may or may not be covered by insurances. In this setting, the community-based health cooperatives are key stakeholders to sustain the CBSI through insurance and local financing mechanisms. Importantly, it was discovered that volunteerism was effectively utilized as a community resource for sustaining health promotion. Examples include volunteer trainers in community exercise clubs and volunteer organizers and coordinators in Kizuna saloons.

Implication in the World View for Healthy Aging

Community-developed ideas and activities attract active collaboration of constituents among health care providers, local government, business, and nonprofit partners (Farmer et al., 2018). Provided that a physical environment exists, such as public spaces and buildings for the activities, the social environment that boosts autonomous CBSI is allowed to flourish. As a result, the seniors can sustain active aging leading to their physical, psychological, and social well-being (Kim, 2020). Both quantitative (Figure 1) and qualitative findings showed that the older males participate in CBSI1, community group exercises, less than the females. The different genders may prefer different kinds of activities for their leisure. Yet, there is room for autonomy and freedom, for community residents to initiate the kinds of CBSI they are interested in, such as stretching, harmonic group and cooking clubs, or poetry and chorus groups (Table 3).

Therefore, an AFE provides physical spaces, barrier-free movement, infrastructure, and access to care along with vibrant social relations that keep later life socially active (Miura, 2019; Ronzi et al., 2018). The CBSI learned about in Japan confirms that social motivation and collective actions maintain older people’s functional ability, civic participation, and human dignity leading to active and healthy aging (Table 2; Figure 2). On the basis of various environmental attributes, the quality of life is boosted as a result of the interactions between individuals and communities (Vanleerberghe et al., 2017). The conceptual model is confirmed by integrating the results of the structural equation model and the qualitative analysis (Figure 2).

The COVID-19 pandemic in 2020 caused the intermittent pausing of CBSI1 (community group exercise for long-term care prevention) and unlimited suspension of CBSI2 (Kizuna bonding saloons) in Tokyo and many parts of Japan. This was essential for the sustainable health promotion and quality of life of the older people living in Japan. Health promotion programs in the communities increasingly applied digital technology to overcome the social distancing (Aung et al., 2020). Digital inclusion is increasingly important for healthy aging communities in the postpandemic era. Future research and innovations are urgently required to allow events to be organized in a safer, new normal style so as to prevent CBSIs from becoming extinct.

Strengths and Limitations

The integration of research findings using the explanatory sequential design (QUAN → QUAL) is the main strength of this study (Archibald et al., 2015). Respondent-driven sampling was used, reaching older adults in different corners of the community. However, future work still needs to be done to explore the experiences of older people living in long-term care residential homes and those who are housebound so as to understand their access to AFEs and CBSI.

Conclusions

It is important to recognize the dignity and human rights of people as they grow older. With global aging, societies are bringing increased attention to the needs of older persons and the role of their families. Quality of life and human dignity are beyond basic needs (Luk, 2020). The evidence reported in this study reveals how independency, autonomy, participation, and dignity of the older person can be realized through CBSI in the AFE of Japan. It is hoped that this evidence can be applied to formulate social policies aiming beyond the basic needs to assure fundamental human rights in Asia and around the world.

Conflict of Interest

None declared.

Acknowledgments

Richard Mann is acknowledged for refining the English language. The authors acknowledge Takashi Yoshioka and Hiromichi Matsumoto, Tokyo Seibu Health Co-operative, Tokyo, Japan, and participants from the Kizuna saloons and Kaigoyobou Taisou, the community-based long-term care prevention exercise group. World Health Organization Centre for Health Development (WHO Kobe Centre), is acknowledged for advice regarding community-based social innovations.

Funding

The Juntendo Research Branding Project is acknowledged.