Nursing for the People withlifestyle-related diseases inJapan
2. Nursing for the people with lifestyle-related diseases:
health promotion, prevention and supporting the persons
living with the lifestyle-related diseases

Japanese Nursing Association

1. Current state of lifestyle-relateddiseases/NCDs in Japan and actions
taken
2. Nursing for the people with lifestylerelated diseases: health promotion,
prevention and supporting thepersons living with the lifestylerelated diseases
3. Japanese Nursing Association in
Action (to be issued soon)

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Glossary• Lifestyle-related diseases：
It is a group of diseases that onset andprogress of which are concerned withlifestyle and behavior factor(s) such as
dietary habits, physical activities, rest,smoking , alcohol consumption, etc.
Examples: Diabetes, hypertension, heartdiseases, cerebrovascular diseases, cancers,
etc.

Source: Ministry of Health and Welfare, the Council on
Public Health on December 8th, 1996

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ACTIVITIES IN THE
COMMUNITY

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Prevention and health promotionin the community• Number of public health centers: 490• Number of municipal health centers: 2,421(As of April 1, 2014)

Source: Office of Community Health, Division of Cancer Control and Health Promotion,
Health Service Bureau, Ministry of Health, Labour and Welfare(MHLW)
http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/tiiki/index.html (Accessed December 18,
2014)

National and local governments implement policies for the purpose ofmaintaining and promoting health of community residents. Pursuant toa provision in the Community Health Act, local governments acrossJapan establish public and municipal health centers.
Public health centers are regional bases for specialized and technicalservices to support the health of the community residents such as
disease prevention and advancement of hygiene standards. Prefectures,designated cities, core cities and special wards run public health centers.
Municipal health centers provide comprehensive health services in close
relation to the community residents such as health consultations, healthguidance and health checkups

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Public Health Nurses take a role inprevention and health promotion• Number of full time PHNs
working at public andmunicipal health centers inJapan: 24,668
Source: 2012 Report of Community Health and Health
Promotion Programs, MHLW

Public Health Nurses (PHNs) work at a public or municipal health centers
all over Japan. To become a PHN, one needs at least one extra year of
training in addition to basic nursing education. The PHN, as a specialistin public health nursing based on health promotion principles, takes theapproach of community activities by getting into community. Throughthe activities, the PHN identifies common health issues in thecommunity. The PHN seeks the path to finding solutions for the issues,
while valuing the partnership and collaborating with the residents.
In the community, the PHN supports people’s autonomous efforts topromote health and acquire self-care skill. The PHN’s work includes
helping individuals promote their health by improving individuals’
selfcare abilities in such ways as providing information, as well as agroup-based approach including support of the mutual actions ofselfcare by the community residents.
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Regulations and activities
concerning lifestyle-related diseases
Health Promotion Act: health consultation, adult healthexamination program, nutrition improvement program,
health promotion program, formulation of a healthpromotion plan, etc.
Act for Assurance of Medical Care for Elderly People:
specified health examination program, specified healthguidance program, etc.
PHNs in the community carry out various activities to prevent lifestylerelated diseases and maintain residents’ health while paying attention tonational policies and identifying health issues in the community.
Pursuant to the Health Promotion Act, the fundamental policies tocomprehensively promote citizens’ health was revised in 2012. The
revision also clearly indicates the prevention of the manifestation andexacerbation of lifestyle-related diseases (prevention of NCDs) as part ofthe policies.
PHNs are engaged in a wide range of programs such as providing
information on the prevention of the onset/exacerbation of lifestylerelated diseases, and the maintenance of health, as well as individual
health education tailored to each individual’s needs, working as a teamwith other concerned professionals, including physicians and dieticians,
as they are involved in planning and program design, implementationand evaluation.
The Act on the Assurance of Medical Care for Elderly People has
obligated health insurers to provide specific health examinations andspecified health guidance for those aged between 40 and 74 targeting
metabolic syndrome since 2008. The PHN plays an important role inproviding health guidance as follow-up of the health examination.
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Specified health examinations for
persons covered by the National
Health Insurance(persons)

The number of persons who took specified healthexamination in FY 2012 (National Health Insurance)

1,500,000
1,000,000
500,000
0
40-45

45-49

50-54

55-59

Male

Female

60-64

65-69

70-74
(age)

Source: All-Japan Federation of National Insurance Organizations Report of status of implementation of
specified municipal health examination and specified municipal health guidance, FY 2012
http://www.kokuho.or.jp/hoken/public/lib/h24_report.pdf(Accessed January 9, 2015)

Those aged between 40 and 74, who are either self-employed or
unemployed have to be covered by the National Health Insurance scheme,
whereby the municipality or special ward is the insurer. Those covered
under the National Health Insurance can undergo the specified healthexaminations in the community. Based on the results, people receive thespecified health guidance based at a designated institution in thecommunity. The rate of people who undergo the examinations increase
with age from 15% for males in their 40s to 40% in their 70s, and fromapprox. 20% for females in their 40s to more than 45% in their 70s.
* Generally Japanese workers retire at age 60 years. Those who were previously
covered by an employees’ insurance scheme need to shift to another type of
insurance after retirement, unless they find another job. One of the choices is the
National Health Insurance.
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The health examination(persons)

Number of persons who underwent health examinations(2012)

20,00015,00010,000
5,000
0
40-49

50-59

60-64
male

65-69
female70-74

75and over(age)

Source: 2012 Report on Community Health and Health Promotion Programs, MHLW

Those aged between 40 and 74 who are covered by (employees’) medical
insurance and their dependents are still the target of specified healthexaminations, but not of the health examinations described on this page.
Those aged between 40 and 74 who are not the target of the specified
health examination, and those of 75 years or older living in a household
receiving public assistance benefits are targets for the health examination
run by the regional authority, and focused on the prevention of lifestylerelated diseases. Some of those who are bedridden at home or who
provide long-term care for a family member will receive a visiting healthexamination if necessary.
The results of the health examinations under this program are followed
up in the form of health guidance and education for the prevention oflifestyle-related diseases and improvement of lifestyle.
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The health handbook(persons)

The number of people provided the health handbook
by municipalities(2012)

600,000
500,000
400,000
300,000
200,000
100,000
0
Male

Femaleage 40-74

age 75 and over

Source: 2012 Report on Community Health and Health Promotion Programs, MHLWThe health handbook is issued by the municipality and is intended forpeople to keep a record of health examinations and guidance and otherinformation necessary to maintain their health, and to use to manage
their own health and ensure an adequate level of medical care. The
handbook is issued free of charge to any persons of 40 years or older
who have received any of the following services:• Health education, health consultation, functional training, visiting
guidance• Specified health examination, general health examination, healthpromotion program
The health handbook also contains information on the prevention oflifestyle-related diseases and the maintenance of health.
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Health education in the community(persons)

Number of group education sessions convened

120,000
100,000
80,00060,00040,00020,000
0
2010

2011

generalosteoprosisclassified by clinical condition

2012(year)

periodondal disease
COPD
medication“general:” Education about the dos and don’ts for everyday life to prevent lifestyle-relateddiseases, the promotion of health, the ideal diet, and other matters essential to health“classified by clinical condition:” Education about the relationship between individual lifestyles
and obesity, hypertension, heart diseases, etc., and how to develop a healthy lifestyle“medication:” Education on precautions when storing drugs and how to take drugs properly,
and information about how drugs work and how side effects develop
Source: 2010, 2011 and 2012 Reports on Community Health and
Health Promotion Programs, MHLWThe PHN plans, designs and implements group health education eventsand individual health education sessions targeting people aged between
40 and 64 years, and reports the outcome of the events and sessions.
Group health education is aimed to promote accurate knowledge on theprevention of lifestyle-related diseases and other health-related matters,
and to raise participants’ awareness to protect their own health.
Individual health education is a continuous health education for thosewith hypertension, dyslipidemia, diabetes and/or a smoking habit tounderstand the characteristics of the concerned diseases
inconsideration with the specific aspects of the individual’s lifestyle andother factors.
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Health consultation in thecommunity(persons)

250,000

The number of persons who took priority health consultation

200,000

150,000
100,000
50,00002008
hypertention
periodontal diseaseclassified by clinical condition

2009

2010

dyslipidemia
osteoprosis

2011
diabetes
women's health2012(year)* A “priority health consultation” is held with the focus on one of the following challenges: “hypertension,”“dyslipidemia,” “diabetes,” “periodontal diseases,” “osteoporosis,” “women’s health” and “classified byclinical condition,” selected by the municipality taking the area’s actual incidence status, etc. into
consideration* A consultation “classified by clinical condition” is held on a specific pathology such as obesity or heartdisease, but does not include hypertension, dyslipidemia, diabetes, periodontal disease, osteoporosis or
women’s health, and takes the individual’s lifestyle, such as diet into consideration* FY 2010 figures do not include the data for some municipalities in Iwate, Miyagi or Fukushima
prefectures due to the impact of the Great East Japan Earthquake
Source: 2012 Report on Community Health and Health Promotion Programs, MHLW

The municipality conducts the health consultation service to individuals
who seek consultation on physical and/or mental health, and thenecessary guidance and advice are given. This service is aimed at
supporting health management at home. The service is staffed by suchprofessionals as physicians, dentists and PHNs. The health consultation
service targets those aged between 40 and 64, who have their abodes
within the boundary of the concerned municipality.
Health consultation services at the municipality level provided in 2012
included priority health consultations, the number of persons who
received priority health consultation was 532,783 in total. Most of themwere pathology-specific consultations including guidance taking
individuals’ dietary and other lifestyle factors into consideration.
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Approaches in the community
Individual approach
Whether a person is healthy, can be categorized into the“potential” group of lifestyle-related diseases, or has
already developed a lifestyle-related diseases, thenecessary information and consultation and/or guidanceservices are provided in accordance with the individual’s
stage
Group (community) approach
Familial lifestyle trends, customs in the community, etc.,
may lead to the development of a lifestyle-relateddiseases in an individual. That is the reason for this styleof community approach

In the community, the PHN is engaged in effective actions to tackle
lifestyle-related diseases while monitoring an entire community throughindividual and group approaches. The PHN endeavors to prevent thedevelopment and exacerbation of lifestyle-related diseases and topromote health by managing people’s lifestyles, ranging from food andnutrition, exercise and sleep utilizing the “sleep guideline”.

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Home-visit nursing also supports
those living with lifestyle-relateddiseases
Users

Care
managers
Healthinsurance

Requests

Long-term careinsurance

Physicians
Home-visits

Written
instructions

Home-visits

Visiting nursing stations, hospitals and clinics

Home-visit nursing is covered under the Long-term Care Insurance
system or health insurance schemes and provided by visiting nursing
stations, hospitals or clinics. A physician’s written order is required tostart the home-visits.
In home-visit nursing, nursing profession supports users long-term
recuperation at home, striving to provide care to restore and promoteusers’ health while minimizing the impact of their illness or disability.
Home-visit nurses provide various forms of care, including managementof chronic conditions and support of family members. Home-visit nurses
support a patient with a lifestyle-related disease, as well as the family, toachieve selfcare, to live with one’s own disease.

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OCCUPATIONAL HEALTHSUPPORTING THE HEALTH OF
WORKERSJapanese Nursing Association15

Occupational health and lifestylerelated diseases
Occupational health coverage
Elementary
education

Lower
Upper
secondary secondary
education education

School health service

Tertiary
education

Workers

Occupational health service

Retirees

Community
health service

Health and healthcare services provided at hospitals and clinics

Pursuant to the Industrial Safety and Health Act, occupational healthensures the safety and health of workers at their work places and promotesa more comfortable work-place environment. From the time when theyleave school until retirement, workers are covered by occupational healthservices.
Japanese people show a rapid increase in mortality from cerebrovasculardiseases, cancer and heart diseases starting from around 40 years old.
Those aged 40 years or older are thus targeted by health examination andguidance services that focus on metabolic syndrome. It can be said thatthose age groups targeted by occupational health services form a significant
generation in the prevention and management of lifestyle-related diseases.
Nurses and Public Health Nurses are involved in occupational health asoccupational nursing staff. The 1996 revision of the Industrial Safety and
Health Act clearly provides for the PHN as one who implements healthguidance services. The PHN plays a major role in occupational healthservices’ effort to prevent and manage lifestyle-related diseases.
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Activity content of occupational
healthWork environment management: to prevent health impairment
and to create and maintain a positive work environment. This
includes countermeasures against smoking.
Work task management: to improve the work method andensure adequate work hours and details, thus mitigating work
load and reducing any negative impact of labor
Health management: to prevent health impairment bymonitoring the relationship between workers’ health andenvironment/content of work, as well as to maintain/promotehealth through overall health support activities.
Formulation of the health plan, health examinations, healthconsultations, etc.
Occupational health have three roles: work environment management,
work task management and health management. Health management
involves a range of actions, i.e., health examination and follow-up
management, health guidance, health consultation and healthpromotion from the planning stage to implementation and evaluation.
Occupational health are aimed to ensure that workers are healthy andable to work. Health examinations are not only intended to achieve
early detection of any health impacts and monitoring of the workers’
health status, but to determine if the worker is able to do his/her task
and can continue with it. Thus the consequent health guidance on
lifestyle-related diseases is not only aimed to improve the worker’s
lifestyle, such as nutrition and exercise, but also to ensure that theworker manages his/her job in accordance with the individual’s status.

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Regular health examination(%)

The number of people who took regular health examinations
and the rate of abnormal findings(Persons)

60.0

15,000,000

50.0

14,000,000

40.0

13,000,000

30.0

12,000,000

20.0

11,000,000

10.0

10,000,000

0.0

9,000,000
2004

2005

2006

2007

2008

2009

2010

2011

2012

2013
(year)

the number of person who took health examination
the rate of abnomal findings in blood pressure
the rate of abnormal findings in blood lipids
the rate of abnormal findings in blood glucose
the rate of total abnomal findings
Source: MHLW Study of occupational diseases occurred between 2004 and 2013
http://www.mhlw.go.jp/bunya/roudoukijun/anzeneisei11/(Accessed January 13, 2015)

The results from the regular health examination, pursuant to theprovision of the Industrial Safety and Health Act, shows an increasing
tendency in the rate of abnormal findings in persons who underwent
examinations. The rate exceeded 50% since 2008. Follow-up after aregular health examination such as health guidance is important forworkers to remain healthy and continue working. The nursing staff inthe frontline occupational health service work in partnership withindustrial physicians to perform interventions that support workers’
health.
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SCHOOL HEALTH AND
LIFESTYLE-RELATED DISEASESJapanese Nursing Association

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School health
Promoting health
Healthmanagement
Health and safety
consideration

SchoolhealthHealth education

Developing
competence inpromoting health

School health is health activities provided at educational settings
pursuant to the provisions of the School Health and Safety Act. School
health includes a health education component, namely, health teaching,
and a health management component, namely, health examinations topromote health and a safe environment for school activities. Various
members of staff and professions are involved in school health, including
the school nurse-teacher (yogo-kyoyu), who takes the major role inobservation of the health status of school-age children, health guidanceand health consultations. The qualification of yogo-kyoyu requires
education at a tertiary institution designated by Ministry of Education,
Culture, Sports, Science and Technology(MEXT) according to a provisionof the Education Personnel Certification Act, but does not require anursing qualification. However, some universities and colleges with anursing program also offer the education necessary to obtain thequalification of yogo-kyoyu. In addition, a person with the PHN
qualification can also obtain a yogo-kyoyu qualification by completing
the required additional education.
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Health management
Regular health examinations are implemented topromote the health of school-age children and schoolstaff. The regular health examinations are followed up
with instructions on preventative measures against
and/or treatment for a disease and other measures
such as reducing one’s exercise or task level.
Guidance and management of daily life is also
provided for children suffering chronic diseases such asheart diseases, asthma or kidney disease. While
avoiding excessive restrictions on activities, the child’s
school life is managed through partnership among theattending physician, school physician, home-roomteacher, parents and yogo-kyoyu.

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Children prone to obesity
(%)

12
10
8
6
4
2
0
5

6

7

8

9

10
male

11

12

13

14

15

16

female17(age)

Source: MEXT Statistical study of school health 2013 (confirmed data)
http://www.mext.go.jp/component/b_menu/other/__icsFiles/afieldfile/201
4/03/28/1345147_1.pdf (Accessed December 12, 2014)

The term “children prone to obesity” refers to children with an obesity index of 20% or
higher against the average reference ranges for weight by sex, age and heightChildhood lifestyle also affects the development of lifestyle-relateddiseases. Another important role of the school health is intervention
to develop favorable lifestyle of children.
Due to lifestyle changes in dietary habits like content of meals andskipping meals, staying up late and not getting enough exercise,actions are required to help children prone to obesity. According to
the 2013 School Health Statistic Survey by MEXT, the trend in obesity
declined from FY 2006 through FY 2011 but has leveled since FY 2011.

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Prevention of smoking habit
(%)
100.0

Smoking experience(2012)

80.0
60.0
40.0
20.0
0.0
junior high school boy

high school boy
NoYesjunior high school girlhigh school girlUnknown

Source: 2012 Executive Report on “Study of the situation of under-age
tobacco smoking and alcohol consumption:” Grant-in-Aid for Scientific
Research from the Ministry of Health, Labour and Welfare (leadresearcher: Takashi Ohida, Public Health, Nihon University School of
Medicine)

Smoking is one of the causes of lifestyle-related diseases in Japanese.
The Act on the Prohibition of Smoking by Minors prohibits smoking byminors under 20 years of age. The Act also states that the retailer oftobacco must check the buyer’s age when selling tobacco, and theretailer may not sell tobacco if a minor may smoke it. Since smoking
from a young age has a major health impact and leads to a lifelong
smoking habit, education for smoking prevention is important.

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Prevention of an alcohol
consumption habit(%)

Frequency of alcohol consumption(2012)

100

80
60
40
20
0
junior high school boy

high school boy

junior high school girlhigh school girldrink nothing

once or twice a year

onece or twice a monthevery weekend

several times per week

everyday

unknown
Source: 2012 Executive Report on “Study of the situation of under-age
tobacco smoking and alcohol consumption:” Grant-in-Aid for Scientific
Research from the Ministry of Health, Labour and Welfare(Lead researcher: Takashi Ohida, Public Health, Nihon University Schoolof Medicine)

The Minor Drinking Prohibition Act prohibits alcohol consumption by aminor younger than 20 years of age. The said Act also prohibits selling
alcohol to a minor knowing that the minor may consume it and provides
measures to take, such as checking the age. However, as the study data
indicated, alcohol consumption by minors is not zero.

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Health education at schools
One component of health education stipulated in MEXT’s curriculum
guidelines is health learning about health promotion and disease
prevention. Not only home-room teachers and health and physicaleducation teachers, but also yogo-kyoyu may teach this component if theymeet certain criteria.
Elementary school:• To keep a balanced lifestyle in terms of diet, physical exercise, rest andsleep for a healthy life and good physical development and growth• To prevent lifestyle-related diseases, which are mainly caused by dailyliving behavior, it is necessary to acquire optimal lifestyle, including abalanced diet
• Such habits as smoking and alcohol consumption may harm one’s health
Lower secondary school:• Disruption in lifestyle such as unbalanced quality and quantity of food in
the diet, lack of physical exercise and lack of rest and/or sleep may cause
lifestyle-related diseases• Smoking and alcohol consumption have negative physical and mental
impacts, and may harm one’s healthUpper secondary school:• To promote health and prevent lifestyle-related diseases, it is necessary topractice a balanced lifestyle in terms of diet, physical exercise, rest andsleep• Smoking and alcohol consumption may cause lifestyle-related diseases. It
is required to have measures for individuals as well as the social
environment
Sources:
MEXT Curriculum guideline for elementary school
http://www.mext.go.jp/a_menu/shotou/new-cs/youryou/syo/tai.htm (Accessed December 19 2014)
MEXT Curriculum guideline for lower secondary school
http://www.mext.go.jp/a_menu/shotou/new-cs/youryou/chu/index.htm (Accessed December 19 2014)
MEXT Curriculum guideline for upper secondary school
http://www.mext.go.jp/component/a_menu/education/micro_detail/__icsFiles/afieldfile/2011/03/30/1304427_002.pdf (Accessed
December 19 2014)

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NURSING CARE AT HOSPITALNURSING TO SUPPORT PEOPLE WHO
LIVE WITH DISEASESJapanese Nursing Association

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Nursing at hospital• In the hospital, nurses are mainly involved in caring
for patients with lifestyle-related diseases• Nurses support patients to learn how to selfmanage their lifestyle-related diseases; i.e., byproviding the knowledge and skills as well as thepsychological support so that the patient can makeindependent decisions about everyday selfcare• The nurse plays the role of coordinator in themulti-disciplinary teamJapanese Nursing Association27

Hospital ward
In the ward, nurses mainly provide the care forpatients in the first (onset) and acute (following
exacerbation) stages.

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Outpatient service
Self-management of chronic disease faces suchchallenges as shorter hospital stay leading to patients
who are discharged before acquiring a sufficient level ofselfcare ability and an aging population resulting in more
people finding selfcare difficult. Nursing intervention at
outpatient service is increasingly required to support
patients’ continued self-management.

At the outpatient service, the nurse works in partnershipwith other relevant professionals such as physicians,
pharmacists and dieticians, and provides consultation andguidance on matters related to home healthcare to postdischarge patients who visit the outpatient service for the
first time and other patients who need continuous
assistance. The nurse aims to learn about the patients’situation by talking with them, and to provides individualcare so that they can continue selfcare of their lifestylerelated diseases.

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Nurse-led outpatient services in
specialized field
Nurse-led outpatient services
n=3,495

No-answer/
unknown
50 institutions

Yes
975 institutionsNo2,470 institutions

Examples of outpatient services• Cancer nursing• Foot care
• Diabetes care support• Care for lymphedema• Support for home care
• Smoking cessation support

Source: Japanese Nursing Association, 2009 Survey on the demand andsupply of hospital nurses

Some hospitals have established nurse-led outpatient services in
specialized field.
In 1992, guidance by outpatient nursing was first recognized as a type ofcare with an medical fee component under the health care insurance
system: the home-based recuperation guidance fee. The 2009 JNA
survey found that 28% of the surveyed institutions had nurse-led
outpatient services in specialized filed. Although not all of these target
lifestyle-related diseases, there are many outpatient services related tolifestyle-related diseases, like diabetes, smoking cessation, home-based
recuperation consultation, lifestyle-related diseases, and foot care. The
medical fee revisions have led to an increase in the number of nursingrelated medical fee components, which resulted in more hospitals
establishing nurse-led outpatient services in specialized filed.
A nurse has to meet certain criteria to provide consultations and othernursing tasks at an outpatient services that can claim for medical fee.
The required criteria includes certain nurse staffing and nurses withadequate experience and training in the respective fields.
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Certified Nurse Specialist and Certified
Nurse plays an important role at nurseled outpatient services in specialized field
Name ofcertification

Numberof fields

Number of
education
programs

Duration of
education

Number ofcertifiedpersons

Certifiednurse
specialists

11

96 graduate
schools
256 programs

2 years
26 units/
38 units

1,266(11 fields)

Certifiednurses21

59 institutions
104 programs

6 months
At least 615
hours

14,263(21 fields)
As of July 2014

Japan does not have a legal system that recognizes the qualifications ofnurses in specialized fields of practice. Various organizations andprofessional societies have their own system of certification.
Credentialing system by JNA is socially recognized and highly esteemed.
Eleven fields of specialized practice are specified in JNA’s credentialing
system of certified nurse specialist(CNS), while 21 fields are specified for
certified nurses(CNs). Among these fields, the fields of cancer nursing
and chronic care nursing for CNSs and the fields of chronic respiratory
nursing, diabetes nursing, palliative care, cancer pain management
nursing, breast cancer nursing, etc. for CNs, meet the requirements fortraining: one of the criteria for receiving medical fee for outpatient
nursing service. These nurses with certifications also play a major role inproviding high-quality nursing to patients.
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