"Healthy Akame!" a Community-Government-University collaboration in community-based participatory research (CBPR) with mixed-method to address health issue in rural Japan community

Background: Public health programs are commonly designed as one-fit for all, to solve problems with high prevalence or cost. However, differences in community’s values and interest might create gaps between health program’s objectives and its implementation. We hypothesized that implementation of community-based participatory research (CBPR) which involve community in every step, can promote more effective program and empower community. This first step of CBPR aimed to assess community needs and develop tailored program for community in rural Japan. Methods: This study applied sequential exploratory mixed-method study (qualitative followed by quantitative). First, we formed community advisory board (CAB) that represented community organization, city officials, and university researchers. CAB conducted group discussions with community residents to identify community’s health issues and strength. Records of group discussions were analyzed with thematic analysis and developed into questionnaire. Questionnaire was sent to all households in community to get priority score of health issues and proposed action, also to assess the willingness to participate in community health program. CAB designed program based on overall results. Results: Ten group discussions with 68 participants generated the following health issues: 1) Diseases, 2) Unhealthy behavior, and 3) Unsupportive environment. Nature, vacant lot, and local farms were considered as local strength. From 1470 households, 773 questionnaires were collected. Cancer, lifestyle-related diseases, and cerebrovascular diseases were ranked highest as health problems. Improving services and access for medical checkup were considered most important. Utilization of public space, local farm, and collaboration with community health office came next for proposed action. Female, people who practice preventive behavior and have high commitment to community were more likely to attend community health program. Almost half participants were unwilling to attend, with majority were work-related reasons. Taking consideration of feasibility and target coverage, CAB decided to develop community program to tackle lifestyle-related diseases. To make advantage of local resources, the main activities centered on health education classes, cooking classes, healthy cafeteria, local farmers market, exercise classes and sports events. Conclusions: CBPR approach was useful to identify community’s needs and to develop a community-based health program that address the needs by utilizing local strength.


Background
Public health programs are commonly designed as one-fit for all, directed for the whole target population instead of individually customized. Studies of health promotion and prevention generally started from diseases which are epidemiologically prevalent, have high morbidity and mortality, or have high cost to manage. For instance, Japan has problems of ageing society with high cost of long-term care (1) and cancer as the leading cause of death (2). The government has designed various programs to tackle the problems, such as the cancer screening program and healthy ageing promotions. However, the utilization of screening program was still low, and the healthy ageing programs were mostly participated by older person only. (3,4) Differences in community interest and values might create gaps between health program's objectives and its implementation in the community. Community values, culture, resources, social construct, and a lot of variables in the community might affect community's perception toward the program and its outcome. A study conducted in Denmark showed that there was a gap between users and providers perception about health promotion services. (5) By filling these gaps, public health programs and community interventions would be conducted more effectively.
In this study, we hypothesized that implementation of community-based participatory research (CBPR) can be a solution to fill the gaps. CBPR is a form of action research, in which the study is done with people, not done on or to people. In the process, CBPR involve community in every step from assessing community needs, planning, executing, and evaluation of the program. Therefore, it fits for health promotion which is supposed to enable people to take action, increase control over the determinants of health, and improve their health. (6) In addition, collaboration and equal partnership with community in CBPR can create a sense of ownership to the program, increasing the chance of program's sustainability.
Considering limited resources and other restrictions, it is necessary to identify the priority of health needs in the community. It is also an important first step in CBPR to assess community needs in order to develop tailored program accordingly. Previous studies had used CBPR approach to identify community health needs (7,8), or to understand community's perception regarding a certain health issue. (9) Along with the process of identifying community needs, researchers could also evaluate the potential challenges as well as strength in the community.
How do people in rural Japan area perceived health issues in their community, and how do they address the health issues? At the time this study started, the authors did not find any literature which gave light on this issue. Therefore, in this first step of our CBPR project, we collaborated with a community and its stakeholders in the area. Our study aimed to assess community's health needs, identify community's strength, and develop a tailored program that could address their needs by maximizing the use of local resources.

Study design
This study implemented community-based participatory research (CBPR) which involved community partners in the whole process of from the planning, execution, evaluation, and reflection of the intervention (addressed as program in this study). (10) In this paper, we reported the first part of CBPR, consisted of community needs assessment and program development which applied sequential exploratory mixed-method (qualitative study followed by quantitative study).

Setting
This first step of our CBPR project took place from July 2017 to October 2018 in Akame region of Nabari city. Nabari city is a small city located in rural area of central Japan. It is one of the cities with "unique" policy on health promotion program within Japan. They have community health office (machi no hoken shitsu) for each of the 15 regions in the city. Initially build to support long-term care in the community, the office then developed into consultation place for all ages, from child health to older adults' caregiving issues. It also serves to support community health promotion and prevention activities. (11) Nabari city also initiated healthy community project (machi juu genki) in 2015, recruiting volunteers to become community health leaders. As one of the city with high proportion of older adults, this project aimed to promote healthy lifestyle and prevent long-term care.(12) Some parts of the city's health promotion budget is distributed to each community development organization (machi zukuri iinkai) to support this project.
Each community was given the freedom to decide on their health project activities. There was no control and evaluation of how the budget was spend, nor standardized evaluation of health activities in each community. Many activities designed were eventual with no clear goals nor objective evaluation. Majority of the activities were conducted in the weekdays and therefore mostly attended by older residents who have retired from work. Our research team from Mie University collaborated with Nabari city officials and community members aiming to design a community-based health program which is more structured, evaluable, sustainable, and can attract broad audience in the community.

Community engagement
The city officials introduced university researchers to potential partner community. First, the university researchers visited the community and had meeting with community development organization representatives and staff of community health office. The community representatives, city officials, and university researcher agreed that an iterative process is necessary to develop a sustainable program. After the initial meeting, university researchers participated in health-related and social activities in community to familiarize with and to observe community's culture.

Establishment of community advisory board (CAB)
To design the study, we established a community advisory board (CAB) that represented community organization, city officials, and university researcher. Members from the community were recruited by recommendation from the leaders of community organization. Fifteen members were initially recruited from community organization, and additional 5 members were recruited from community health leaders (who were recruited and trained by the city). In addition to 2 city officials who oversaw the community, 2 staff of community health office, 2 university researchers, and 1 physician from the city hospital, the CAB had 27 members in total. All CAB members had equal rights, and each played their role. University researchers were responsible for all procedure necessary for the research. Community partners played role as bridge to the community to recruit participants, gathering data, and give contextual insight for the findings. Study design, program planning, and all decisions that affect the program were discussed in CAB meeting.

Data collection
Our target participants were adult residents (age 20-year-old or older) in community who were capable to make decisions independently. First, we conducted qualitative study to assess people's perspective about health issues in the community, community's strength, and proposed ways to solve the issue. CAB held a community forum (world café) with community residents from various age group and gender. Participants of the forum were divided into 10 groups of 6-7 people, each facilitated by one CAB member. Each group representative shared the group discussion's summary to all participants. Discussions in each group were recorded and transcribed verbatim for qualitative analysis.
Second, a quantitative questionnaire survey was conducted to score the importance of health issues and proposed action. Items in questionnaire was developed by the categories extracted in the qualitative analysis above. All the items were measured with 5-point Likert scale (1 is least important, 5 is most important). Afterwards, self-administered questionnaires were distributed to all households in the community and collected anonymously. We also gathered data about respondents' prevention practice, past participation in community activities, community identity and commitment to community (will be explained in another paper), and willingness to participate in community health promotion program. Representatives of each sub-region helped to distribute and collect the questionnaire.

Analysis
Qualitative data was analyzed with thematic analysis.(13) Initial qualitative analysis was conducted with NVivo 10 software (14) to extract keywords, generate codes, and categorize into themes. The 1 st and 2 nd authors revisited the data to check codes, categories, and themes to make connection among themes. Themes, categories, and quotes are presented in table form for better understanding.
Participants' sociodemographic data, health issues priority score, proposed action score, prevention practice, past participation in community health activities, community identity, commitment to community, and willingness to participate in community health program were presented in descriptive statistics. To see how predictor variables (sex, age group, education background, prevention practice, past participation in community activities, community identity, commitment to community) determined willingness to participate in community health program, we conducted logistic regression analysis. Model with lowest Akaike Information Criterion (AIC), lowest residual sum of squared (R 2 ), and highest Nagelkerke Pseudo R 2 was chosen as best fit model. Multicollinearity was confirmed using variance inflation factor. Statistical analysis was conducted with R version 3.5.2(15) with readxl (16), psych (17), tidyverse (18), dplyr (19), DAAG (20), and BaylorEdPsych(21) packages. CAB discussed both quantitative and qualitative results to discuss priority issue and develop a one-year health program.

Qualitative results
Community forum was attended by 68 participants, 10 young adults (20 to 40 years old), 18 middle-age people (41-64 years old), and 40 older adults (65 years old and above). More than half of participants were female. When the participants discussed about "health", they shared similar goal: to be able to life independently for as long as possible (longer healthy life expectancy).
The group discussions generated the following sub-themes for health issues: 1) Diseases, 2) Unhealthy habits, and 3) Unsupportive environment. Participants discussed that health problems were not only the existence of diseases, but also about the unhealthy behavior and the environment that did not support healthy behavior. In addition, mental health was also considered as important, such as stress, depression, and dementia. The discussions also emphasized the importance of social connection and communication.
Nature, existing community networks and communication platform were considered as community's strength that has potential to improve people health in the community. The area was surrounded by beautiful forest, waterfall, parks, and fertile land. The surrounding nature was thought of having the potential not only as tourism spot, but also place to exercise (walking, hiking, etc.). Many people in the community farmed, from small housing scale to large commercial scale. The farming activity was thought as beneficial for keeping people physically active, and the older generation could teach the younger generation. If the community has farmers' market that sell vegetables produced locally with prices more affordable than supermarket, the residents in community could also obtain healthy ingredients more easily. The existence of community health office, community sports and social club, were considered as potential network that could strengthen community capacity.
Other than improvement inside the community, improvement of services and access to health facility for medical checkup were also considered important. There were only few clinics located in the neighborhood, and no facility provided comprehensive medical checkup and screening. To get various cancer screening, residents must go around to several different places. Public transportation did not pass the area frequent enough, so access to healthcare facility was difficult especially for the older adults. Relationship of each themes were explained as diagram in figure 1. Table 1 provided themes, categories, and quotation in details.

Quantitative results
From 1470 households, 773 questionnaires were collected. We categorized participants into 3 age groups; young adults (20 to 40-year-old), middle-age (41 to 64-year-old), and older adults (³65-year-old). The proportion of male and female respondents was balanced. Majority of respondents graduated from high school or above and were still working. More than half respondents reported that they practice preventive behaviors, with healthy diet, going for medical checkup, and not smoking as the most frequent choices. More than half participants seldom or never attended health-related activities in their community. Details on participants' characteristics are described in Table 2.
The proportion of people willing and unwilling to attend community health program was similar, with people above 60s were more likely to attend. We asked participants to answer the reasons for not attending, and the top answers were work-related (e.g. do not have time because work is busy, too tired working on weekdays so wants to rest on weekend, thinking of going after retiring). The other reasons for not attending were: busy as caregiver (for older family members or children), unwilling to do it in group (wants to do in own pace, wants to avoid troubles with other people, shy in front of other people, etc.), and because there was no friend in the same age to attend with.
We asked participants to score the importance of health issues and proposed action using Likert scale from 1 (not important) to 5 (very important). The score was calculated for each item and ranked for each age group (Table 3). For all age group, diseases-related health issues were considered of high importance (cancer, cerebrovascular disease, lifestyle-related diseases). For the proposed action, participants expected that improving services and access to medical checkup, opening vacant lot as public open space for exercise, and collaboration with community health office would improve their health.  Numbers in bracket () show the top 5 of highest priority score. Some items received same total score and shared the rank.

health prevention practice, participation in community activities, community identity (common bond to community, common identity to community), commitment to community
We conducted logistic regression analysis to see which of the respondents' characteristic that contributed to their willingness to participate in community health program. The predictors with significant contribution were female, moderate to frequent past participation in community activities, practiced more preventive behavior, and high commitment for the community were more likely to attend community health program (table 4).

Priority Decision and Program Development
Top priority for health issue was cancer, and improving health care service for medical checkup for the proposed action. Cancer has multifactor risks and the outcome was hard to see in short term. Likewise, improving health care services was beyond reach and CAB could only advocate for it. In addition, the city has actually been conducting mobile integrated cancer screening program in public places such as community center, public health center, and city office.(22) Therefore, advocating integrated cancer screening facility was not priority. Rather than that, circulating the information about mobile integrated screening program was more realistic.
Considering the feasibility, CAB decided to tackle the next health issue in the priority list which they can work on, has direct health/social outcome and intermediate health promotion outcome that can be evaluated in relatively short time: lifestyle-related diseases.
To make advantage of the local resources, the main activities centered on 3 themes: health, exercise, and nutrition. For health themes, health education classes were scheduled to raise awareness and knowledge, and health measurements were planned to give participants information regarding their health status. Healthy cooking classes and community cafeteria were planned to use local ingredients provided by local farmers, and to provide chance for social meeting. At the same day, farmers market will be held to promote local farming products. We developed health diary to record exercise and health measurement results. We also introduced food record and measured dietary intake to promote healthy balance diet. Utilization of vacant lot in community, walking events around the area, and exercise classes were planned to endorse physically active lifestyle. Activities were mainly planned in the weekend to attract the working generations to attend.

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 lifestylerelated 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 lifestylerelated 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 wellknown and have been researched extensively. (35)(36)(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)(46)(47)(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)(50)(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.

Conclusions
The main health concern in our target community was diseases centered. In relation to that, people expected that improving health care services would improve their health. In addition, utilization of resources in community were also expected to benefit people's health. While results from qualitative study showed importance of unhealthy behavior as health issues, respondents from larger participants in quantitative study felt less necessity to improve personal behavior, such as smoking cessation and reducing alcohol consumption. It showed that people who voluntarily participated in community forum might have better understanding about behavior impact on health. Female, people who had previously participated in community activities, practiced preventive behavior, and had high commitment for community were more likely to participate in community health program.
Utilization of CBPR approach was useful to identify community's perception on health problems, their needs, strength, and determinants to participate in community health program. Understanding these characteristics, the CAB had better insight to develop a tailored community-based health program that was within people's interest and unique to local strength. Involvement of community members who understood community's value had enabled to decide on health issue that was important and feasible to address promptly with available resources. It also helped to develop program that was feasible to conduct and could be sustained in the community.

Ethics approval and consent to participate
This study has been approved by Clinical Research Ethics Review Committee of Mie University Graduate School of Medicine/School of Medicine/University Hospital (No. 1767). CAB members, participants in group discussions, and questionnaire's respondents gave consent to participate in the study prior to start of our project.

Figure 1
Relationship of health problems, proposed action, and goals in the community. Unhealthy behavior and unsupportive environment were considered as predisposing factors that contribute to diseases, which will affect one's health life expectancy. Improvement of services and access to medical checkup and screening, utilization of local strength and potential, strengthening community capacity, and facilitating behavior change were thought to improve people's health, resulting in longer healthy life expectancy.