Pleasant, sustainable care prevention—“Relaxation salons” developed in collaboration with the community
The Case of Taketoyo Town, Aichi Prefecture
Introduction
From 2013, the basic policy
direction for Health Japan 21 (thesecond term) is to close the healthgap by building a good social
environment that supports healthyliving in all generations. The Care
Prevention Manual (March 2012,
revised) also advocates“community-building to preventthe need for nursing care.”In Taketoyo Town we have opened a number of “Relaxation Salons” since 2007 in a
primary prevention project to help elderly people avoid the need nursing care. This
project aims to develop a social environment that makes it easy for elderly people touse the service and to promote community-building by calling for volunteers to
support this social environment.
This article describes the

Figure 1

Location of Taketoyo Town

following in relation to these
activities: (1) Outline of the townof Taketoyo, (2) History of these
efforts, (3) Activity content, (4)Results of activities so far, and (5)Issues and outlook.
(1) Outline of region
Outline of Taketoyo anddemographic composition
Taketoya is a town with a landarea of 26 km2 located near the

Taketoyo Town

center of the Chita Peninsula inin Aichi Prefecture1

western Aichi Prefecture, Japan (Figure 1). It has a long history as a port and railroad
town, and developed rapidly after World War II as an industrial town that played arole in the coastal industrial zone. With this development the town’s population greweach year, until recent years when this growth has leveled off. The current population(as of the end of fiscal 2011; the same for all statistical figures below) is 42,635
people.
Reflecting its industrial structure, Taketoyo has had a higher proportion ofworking-age people than neighboring towns, and was called a “young town.” However,
the elderly population has been gradually increasing in recent years, to 8,728 people.
In 2000 when the long-term care insurance system was introduced the proportion ofelderly (aged 65 years or over) was 12.8%, compared with 20.5% today. Even so the
proportion of old-old people (aged 75 years or over) among elderly people is 40%,lower than the national average of 52.4% (at the end of fiscal 2010), and the town ischaracterized by having many relatively young, vigorous elderly people. A low
percentage of people aged 65 years or over have received certification of long-termcare need (11.9%; national average 17.8%) and of them a low percentage havereceived certification for higher levels of care need (Care Need 4: 13.8%, Care Need
5: 8.2%).
Public health activities system
The town currently has nine full-time public health nurses, who are assigned mainly
to the Health Section, Health and Welfare Department and are active in a public healthcenter located in the center of town.
With the introduction of the long-term care insurance system, the public healthnurses were assigned to other sections in addition to the Health Section, where they
had previously been over-concentrated. Currently, two public health nurses are
assigned to the Welfare Section in the Health and Welfare Department, and one isassigned to the Childcare Support Section in the Health and Welfare Department (bothsections are within the town government office main building).
The public health nurses assigned to the Welfare Section are mainly in charge ofhome-visit surveys for long-term care insurance certification. The nursing careprevention project is mainly overseen by the Health Section and the Community
Comprehensive Support Center (the Welfare Section entrusts this project to the Social
Welfare Council. Currently, no public health nurses are assigned there).
2(2) History of activities
Collaboration with Nihon Fukushi University
The Mihama Campus of Nihon Fukushi University is located in the town ofMihama, which neighbors Taketoyo to the south. Nihon Fukushi University and
Taketoyo have worked together since the introduction of the long-term care insurance
system to conduct surveys on the health and lives of general elderly people (thesurveys target all people aged 65 years or older who have not received carecertification; this includes people targeted by the current secondary prevention
project). The survey covers a wide range of items, including elderly people’s state ofhealth, level of independence in daily living, lifestyle including frequency of goingout and participation in community organizations, social capital including affection
for community in which they are living, years’ of education, and economic status.
These surveys are currently conducted every three years in joint research by Nihon
Fukushi University and local governments nationwide, including municipalities in the
Chita Peninsula area. Changes in subjects over time are followed (in addition tochanges in responses, the survey looks at changes in status of certification of
long-term care need, and death). The circumstances of elderly people revealed in thesesurveys and the health gaps with neighboring municipalities are identified andanalyzed. Today the health gap between people has become a well-known area ofconcern, but the university has focused on this since 1999 and has examined thebackground and regional characteristics that give rise to these gaps. It is also studying
the kinds of care prevention measures that will be effective in the future.
Town public health nurses previously had almost no contact with such survey
studies, and at first did not fully understand the meaning of the research. Looking
back, the surveys enabled understanding of a wide range of residents’ characteristics,
inclinations, and thoughts that could not be understood from health checkup data. At
the time, however, public health nurses though the meaning was in gathering
information on-site itself, and continued to set up and run various public healthprojects without considering the data they were gathering, relying on their “intuitionand experience” as public health nurses rather than verification from objective data. It
did not take long before we realized that these surveys provided evidence and hints
for our subsequent projects.
Startup of “salons as a care prevention model project”
At the time of the revisions to the long-term care insurance system in 2006, a major
3focus of attention was the importance of preventing the need for nursing care. Several
such “care prevention projects” had been undertaken as government initiatives up tothat point. Programs such as exercise and relaxation to prevent falls and nutritional
improvement programs were planned as individual classes, with instruction provided
by licensed specialists (for a fee). This limited the number and frequency of theseclasses, in addition to which nearly all the classes were held at public health centers.
The concept of “care prevention” (that is, preventing the need for nursing care) had
also not spread at that time; few people participated in most of these classes and it
seemed that the only participants were certain repeat participants who had a high levelof health awareness.
Professor Katsunori Kondo of Nihon Fukushi University was quick to seen thelimitations to national movements and secondary prevention. One day before therevisions had been introduced he asked us if we would like to try holding salons for
elderly people in Taketoyo as a care prevention model project that emphasized
primary prevention.
The “salons” would be places where local residents gathered at community centersor other public facilities. They would be run by these people themselves and be places
where they could make friends and socialize. Salon projects for elderly people hadalready been implemented by many local governments nationwide, but in Taketoyo
there were not yet any that had been made open to the general public.
It was becoming clear from university research that an effect could be expected byusing such “salon” activities in care prevention projects. For example, it had beenshown from athree-year follow-up
of people who meet

Figure 2 Participation of community activities
and incidence of dementia(from the data of follow-up from 2003 to 2006)

friends with a highPeople who participate in community activities
have low risk of dementia

who participate incommunity
gatherings that they
were 1.5 to 2 times
less likely to develop
dementia (Figure 2).1)
In addition,
self-motivatedRelative risk of dementia

frequency and people

2.5

2.08

2.0

1.53

1.5
1.0

1.00

1.00

0.5
0.0

Male

Participation of community activities

4

FemaleYesNoparticipation in gatherings as volunteers associated with the running of these meetings
was found to be effective in preventing the need for care in both men and women. 2)
Considering these circumstances and research findings, the Taketoyo Relaxation
Salon (in the following, “Salon”) Project Conference was started by the local
government administration and university. Visits to inspect trial sites were also madeand the plan for a model project was brought into focus. At this time it was agreed thathaving residents play central roles and the government provide support so that thesalons could be continued comfortably and pleasantly were important to the program.
It had been shown from an investigation of individuals who made their first
application for long-term care need certification, by checking their status one year
before the application was made, that half of them had none of the risk factors (historyof falling, depression, isolating themselves at home, malnutrition, decreased oral
function) for coming to need nursing care. 3) For this reason the salons targeted allelderly people and not just high risk individuals. The condition most commonly citedby residents for participation in community projects was the closeness of the place
where they are held, 4) and a general policy was set of establishing salons in various
places so that even elderly people could walk to them without difficulty.
Efforts did not stop as simply holding the salons as a program to prevent care need;changes before and after implementation were compared and the effect of the salons
was examined.
(3) Activities
Collaboration with residents—Nurturing social capital
In July 2012 the Ministry of Health, Labor and Welfare announced revisions to the
Basic Plan to Promote Community Health Measures. These revisions emphasized theimportance of resident-centered healthy community building and nurturing and theuse of social capital, but the Taketoyo salon project had been carried out withcollaboration with town residents as a basic condition from the beginning (2007).
It was necessary to find a large number of people (community volunteers) so thatthe salons could be continued long-term and in many places. For this purpose,
meetings to explain the project to community residents and call for volunteers were
held in October 2006. These meetings described the care prevention effect of theupcoming salons, and direct appeals were made for the need for volunteers. Twoworkshops were held starting in November with about 50 residents who agreed withthe meaning of the salons and expressed a desire to cooperate, and through these5

workshops a shared image was developed for the kind of salon people would like tomake and be involved in. In this way common key words were identified and “keyphrases” were adopted to express the image we were aiming for in the Taketoyo salons.
These key phrases were (1) Salons that make people smile, (2) Salons where the ideasof each person are respected, and (3) Salons where people meet and create bonds.
These key phrases are still posted at every venue even today, five years after thestart of the program. They are recited together before each event and have taken rootas the “core values” that should not be forgotten. When new venues are opened, thesekey phrases are always presented to give direction for people’s efforts.
Through such work, the attitude that the project is run not as a government
initiative but as an expression of residents’ own ideas has slowly pervaded.
Operation and current status of the salonsAfter all the workshops, a preparatory committee was selected to make concreteplans. Through several meetings three locations were selected for the first modelneighborhoods. Common rules for the operation of the salons were then alsoestablished based on the residents’ own wishes (there would be a participation fee of
100 yen per time, the participation fee would be paid by participants and volunteers
alike, people are free to participate at any salon without a reservation). Other things
such as the frequency and duration of meetings and program content were decided
through discussion among the volunteers at each site. After first communicating thatthey would like to make the frequency of the salons something that would not be aburden to the volunteers, groups at two sites decided open the salons for half a day
once a month, and a group at one site decided to open the salon for a full day twice amonth.
For the first year after start of the salons, the municipal government Welfare
Section and the Community Comprehensive Support Center provided full intervention
in support of the salons. This intervention consisted mainly of training volunteers andfinancial assistance. From the second year operation of the salons was entrusted fully
to the volunteers, with the volunteers at each site doing everything from projectplanning and operation to managing the budget. At first some volunteers were uneasy
about being entrusted with the project and the decrease in support from the town, andsome expressed misgivings and satisfaction. After a year had passed, however,success in finding their way in operating the salons seemed to have become a sourceof great confidence for them, and finally a smooth transition was made to operation by
6the volunteers.
With the operational flow at these three initial sites as a model, salons were later
opened at one or two new locations each year. As the number of sites increased so did
the number of participants. In fiscal 2011 there were eight sites and the total numberof visits to the sites exceeded 8,000, comparable to the elderly population of the town
(Table). Salons in two new locations opened in June and November 2012, and thetarget number of 10 locations for the salons (based on an estimation of the number ofsalons needed so that all elderly people in the town could walk to one within 15
minutes) was reached one year earlier than the target year of 2013. Awareness of thesalons within the town has also risen, and today 10% of the actual number of elderly
people who have not received long-term care certification participate. The salons havedeveloped into a key feature of the town’s care prevention projects.
Public health nurse intervention
From the start of the salon project there was cooperative involvement by the
Taketoyo Town Welfare Section, Health Section, and Social Welfare Council, Nihon
Fukushi University, and Seijoh University. Currently, the main interventions areprovided by the Community Comprehensive Support Center, but Health Section
public health nurses also go around to each salon location 2–3 times a year to provide
health consultation and health talks to participants. They also attend the monthly
meetings of the “Relaxation Salon Management Council” and meetings of people incharge of office work, and are engaged in consultations for the selection and operationof new sites.
(4) Results of activities
In Japan’s aging population, living long in a state of health is desired by both
Table Yearly trend of the number of participants for the “Relaxation salons”
Fiscal year
Population of elderly (people)
Number of places of salons (places)
Total times of opening salons (times)
Actual number of participants (people)
Total number of participants (people)
Proportion of participants among elderly
without long-term care certification (%)

2007
7,471
3
39
401
2,341

2008
7,874
5
66
583
4,553

2009
8,259
7
91
637
5,323

2010
8,368
8
109
637
6,441

2011
8,728
8
136
794
8,084

8.3

8.4

8.7

9.9

10.4

as of March 31 in each fiscal year7

individuals and society. For this people need to maintain and prolong their
independence to the extent possible, and delay the time when they become frail orcome to need care. To achieve this it is important to start care prevention while people
are still healthy and vigorous. This “prevention” perspective is the area of specialty of
public health nurses, and from this perspective we have felt, based on the difficulty of
secondary prevention and our experiences in the salon project, that there are limits towhat is possible with government initiatives. The efforts of community residents
themselves and activities by local organizations are crucial.
When developing these salons was first suggested, I was, to be honest, concerned
about how many local residents would actually raise their hands to volunteer. Whenthe lid to the project was actually opened, however, the response was greater than I
had imagined. Many people offered their cooperation with a sense of purpose basedon the idea that this project was also important for them personally. I feel that they
were supported by that idea in continuing their involvement in starting up this big
project.
The anticipated effect also appeared. Each year, with the cooperation of Seijoh
University, a “vitality check” of participants and volunteers (a questionnaire on daily

8life activities and psychosocial condition, and a survey of cognitive function andphysical strength) is carried out (in fiscal 2012, such checks were carried out at six ofthe 10 sites). In the period from 2007 (when the first salons were opened) until 2010,
a comparison of data from people who received both an initial check and a check after
one year showed increases of about 20% in “having someone to talk to,” “having
someone to do things together with,” and “feeling that I am useful,” respectively, inboth volunteers and participants 5) (Fig. 2). Even though the salons are held only onceor twice a month, they were found to nurture social support and networks. Secondary
prevention subjects also participated in the salons, and among the 200 generalparticipants who received “vitality checks” at six sites in 2012, 64 (32.0%) were
elderly people deemed to have motor function risks. Although a simple comparison
cannot be made, this corresponds to 0.7% of the entire elderly population of the town.
With the addition of participants at other salons where vitality checks were not
performed, the proportion would probably exceed the 0.8% that participate insecondary prevention projects nationwide (2011 Care Prevention Project Report).
(5) Issues and future outlook for the salons
Currently the salons continue to run stably, and the target number of sites has beenachieved. From fiscal 2013 we are considering opening new “calisthenics salons” thatspecialize in calisthenics to increase the participation of men who lack stimulationand to enhance activities for people who are targets for secondary care prevention.
Through the salons I have made new connections with many town residents. I cameto understand the ability of residents to implement local organization activities, which
had not been fully revealed and used previously, and think that we have been able toincrease the number of powerful allies for future public health nursing activities. The
shift from public health programs that were excessively concentrated at public healthcenters to a program in which public health nurses moved out into the community, therightful place for their activities, has also been a valuable experience for me.
As expressed by the key phrases, all of the salons are filled with smiling faces andparticipants can participate at whichever site they would like at their own pace,making new acquaintances and reuniting with old ones. Participants also feel anawareness of their roles, with each person doing what they can at a level they are
comfortable with.
In consideration of the policies of Health Japan 21 (the second term), announced inJuly 2012, Taketoyo Town has also begun the “Second Stage Healthy Taketoyo 21
9Smile Plan,” a 12-year health promotion plan. The perspectives advocated in the planof closing the health gap, raising social capital, and developing a social environmentthat supports and protects health may seem novel at first glance, but the mostfundamental part—community building and having community residents themselvesplay the main roles—remains unchanged. There is also a renewed awareness of thefact that the approaches used in the salon project were effective in achieving its goals.
The abilities of residents that were felt through this salon project are true social
capital, and something of real value for Taketoyo. In the future, together with thepeople living in Taketoyo, we would like to continue to build and develop salons withresidents in the main roles. We would also like to be public health nurses who
continue to go out into the community for activities and encounter many smiling
residents.
● References
1) Tokunori Takeda, Hiroshi Hirai, Katsunori Kondo. Factors related to the onset ofdementia in community-dwelling elderly—From a 3-year longitudinal study.
Health and Labor Sciences Research Grant Longevity Integrated Research
Project, “Study on Comprehensive Support Focusing on Psychosocial Aspects toPrevent Dementia.” Fiscal 2007 General and Collaborative Research Report,
pp53-62, 2008. (in Japanese)
2) Hiroshi Hirai, Katsunori Kondo, Toshiyuki Ojima, et al. Investigation of risk
factors for certification of long-term care need in community-dwelling elderly.
Japanese Journal of Public Health, 56: 501-512, 2009. (in Japanese)
3) Katsunori Kondo. Health Gap Society—What Is Undermining Our Spirit and
Health. Igaku Shoin, 2005. (in Japanese)
4) Taketoyo Town, Nihon Fukushi University. Collaborative Research Report for
Taketoyo Care Prevention Model Project. 2006. (in Japanese)5) Taketoyo Health and Welfare Department Welfare Section. Health Promotion andCare Prevention. Fifth-Stage Taketoyo Geriatric Welfare Plan, Care Prevention
Insurance Project Plan—Fiscal 2012–2014. pp17-20, 2012. (in Japanese)
Translated from the Japanese manuscript written by
Miki Kobayashi (Health Section, Public and Welfare Department, Taketoyo Town)

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