Nursing for the People withlifestyle-related diseases inJapan
3. Japanese Nursing Association in Action

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
ActionJapanese Nursing Association

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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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ACTIONS TO PREVENTLIFESTYLE-RELATED DISEASES:JNA GROUP SUPPORT MODEL

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Public Health Nurse-led
actions to prevent lifestyle-relateddiseasesSpecific Health Examination and Specific Health Guidance programs
started in 2008. There are high expectations of public health nurses(PHNs) to provide health guidance. JNA developed a “JNA Group
Support Model” in 2006 as a health guidance program to be
implemented by PHNs. JNA also implemented a model project for 3year, which started in 2007, utilizing a JNA Group Support Model for
activities of lifestyle-related disease prevention; and positive results
were achieved.
This model project involved participation by 272 professionals from 24
providers, including PHNs, nurses, registered dieticians and others. The
target groups of this model project were insured persons and theirfamily members aged between 40 and 74 years.
The first step of the model project was mass screening by providers to
identify patients with Metabolic syndrome. This was followed by PHNs’
educating the risk groups, with a focus on their lifestyle including dietand daily life. A JNA staff support team helped the PHNs with theirteaching sessions.

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Prevention of lifestyle-related diseases
JNA group support program
Place of living (daily life)
To become aware in the “Place of living” a “Place foractivities” is utilized
Laboratory
data(HbA1c)← 3 months →Group
Conversation

Laboratory
data(HbA1c)← 3 months →Group
Conversation

Laboratory
data(HbA1c)Group
Conversation← 3 months →Continuation ofhealth-promoting
behavior

Laboratory
data(HbA1c)Group
Conversation

Place for activities (Place of support)

Support continues
for the programspans two years

Specific elements of the JNA Group Support Program are as follows;
1. Participants meet every 3 months to reflect on their life based on laboratory dataand group conversation;
2. Participants self-check their own laboratory data and diet;
3. Support between the group conversations are provided via phone calls, e-mailmessages and letters;
4. Aim is to graduate within 2 years.
The main activity in the JNA Group Support Program is group conversation in a small
group of 6 or 7 people, which allows the participant to highlight certain aspects of
his/her own lifestyle that he/she is not normally aware of, by comparison with theothers. The participant then experiments with what he/she realized during the activity
in his/her own life, and aims to incorporate it as his/her own habit. In addition, theparticipant self-checks changes in the laboratory results so that he/she can understand
how lifestyle is related to his/her physical status and can become able to interpret thelaboratory data. Furthermore, the participants learn to monitor the actual state of
their own lifestyle throughout the year; because the basic unit of real life is a year:
people live through annual events and school and/or business year events. In addition,in consideration of possible relapse, the program has a mechanism whereby people
can participate when they feel a need. This allows support to continue until the newlifestyle becomes the participant’s own, and therefore the program spans two years.

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Contents of JNA group support model
1. Looking at the process
2. Looking at the actual state of diet
3. Looking at the state of control
4. Looking at the actual state ofdeveloping habits
The prevention of lifestyle-related diseases requires a person to review
his/her lifestyle and to obtain and continue with the new lifestyle.
What specific actions to take during this process differs from person toperson. The program is aimed to have the participant experience thefour points above through group conversations, assess their own state,
identify their own challenges and obtain the necessary aspects fortheir own actual daily life. During the 3-month period between groupconversations sessions, the participant receives PHN’s support while
experimenting with the new knowledge they have discovered throughgroup conversations about their own daily life, in the form of phone
calls, e-mail messages and letters.

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1. Looking at the process• By observing the course of asymptomatic
lifestyle-related diseases thorough the casewith similar challenges that participants have,he/she will reflect on his/her own lifestyle.

In the “Looking at the process” , the participant examines a case withsimilar challenges as his/her own, so that the participant can see thatlifestyle-related diseases are the issue close to him/her and becomesaware of it. “Top-student” cases will not be used for case study,neither a case who later suffered a stroke (because the participant
may feel threatened that “You will be next.” The participant will
become aware of his/her progress in the disease course by looking atother cases. Furthermore, the participant will also become aware of
his/her own situations through group conversations that help
highlight his/her situations in comparison to other cases andparticipants. Through these activities, the participant will becomeaware of the lifestyle-related diseases that is the issue close to
him/her.

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2. Looking at the actual state of diet
• Participants will review the quantity of meal
to see how much and what the participant iseating.

In “Looking at the actual state of diet” , the participant learns hands-on how
to know the amount of the meal he/she eats just by looking at them,without having to rely on a professional like a dietitian.
Photographs or actual materials of common everyday food are displayed,
and the energy content is indicated with a number of  ( equals 80 kcal).
The participant lists the food he/she eats, and by using the photos andactual food shown, can count the number of  in his/her own meal to grasp
how much energy he/she is taking. By checking the actual quantity of foodin a day’s meals, the participant’s vague sense of “watching what I eat”
connects with awareness of where the problem lies. Doing this activity
while discussing it in the group helps the participants become aware thefood issue in their own daily life.
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and will understand why test results change
by looking at the process.
Progress of activities andlaboratory data (changes in HbA1c)
7.5
7
6.5
6
5.5

At the healthexamination

First

SecondThird

Fourth(Image)In “Looking at the state of control”, the participant will understandthat laboratory data are not the data used to diagnose a disease, butdata used to look at the daily life. By graphing laboratory data for ayear, the participant will learn that the laboratory data reflect the stateof the daily life. By sharing causes of laboratory data changes in groupconversations, the participants can become aware of an aspect of
their daily life that they have not realized before.

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4. Looking at the process involved
in developing habits• It takes time to review what has alreadybecome a habit, and to improve on it anddevelop a new habit. There may also be
relapses; therefore, the participant must findthe conditions that will help him/her tocontinue.
“Looking at the process of developing habits” does not involve tocheck whether the efforts to improve can be continued. This partrather means to value the shared awareness that more likely thannot, such endeavors do not continue. In many cases, laboratory data
will improved once, but then deteriorate again if the new habit
cannot be kept. By confirming the difficulty to continue and develop
habits in group conversation activities, the participants will becomeaware of the necessary conditions to continue.

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Outcomes• In most laboratory tests, such as weight,
abdominal circumference and HbA1c, approx.
60% of the participants “improved orremained constant” (2007)• Reduction in number of at-risk persons
between 2007 and 2008 health examination(2008)
Analysis of the results of the three-year-long JNA Group Support Model
project of actions to prevent lifestyle-related diseases confirmed a certain
level of its effectiveness.
Motivation is said to be the key factor in prevention of lifestyle-relateddiseases. The JNA Group Support Model utilizes group interactions.
Participants are supported by other members of the group along theirjourney of progress and relapse, and can become aware of their needs as
they are mirrored by their comrades. The length of activities is also
determined with the purpose of becoming aware of the difficulty tocontinue and to recognize the necessary conditions for continuation.
The JNA Group Support Model is promoted for dissemination and use
through publicity on the JNA website and the creation of a pamphlet andthe facilitator’s manual. In addition, the following book was published topromote this program.
Setsuko Hisatsune, Kumiko Ii. Group support to prevent life-style relateddiseases. Tokyo, Japanese Nursing Publishing Company, 2009. (inJapanese)Japanese Nursing Association

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SMOKE CESSATIONFOR NURSES

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Overview of JNA actions for
tobacco use
1999

Declaring actions for nurses’ tobacco use

2001

Statement of actions for tobacco use
Nurses and tobacco use, actual situation
survey2002

Smoking cessation policy adopted forvenues where JNA-hosted events are held
and the surrounding area

2003

Nurses and tobacco (pamphlet)

2004

Nurses’ action plan for tobacco use
Smoking cessation support guide for nurses

2005

Smoking cessation support pamphlet forindividual nurses

2006

Survey of actual situation of tobacco use
among nurses

2013

Survey of actual situation of tobacco use
among nurses

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The statement of actions for
tobacco use
1.
2.
3.

4.

JNA will proactively engage in actions for tobacco
use as a profession who protect public health
JNA will support nurses undergoing smoke cessation
JNA will promote a smoke-free environment at
health and/or welfare facilities to prevent passive
smoking
JNA will proactively engage in education aboutsmoking cessation and protecting from passive
smoking for nursing students* 2001 statement stated “3. JNA will promote a smoke-free or smoker separation
environment at health, medical and/or welfare facilities to prevent passive smoking.”
However, the Japan Council for Quality Health Care 2004 Accreditation Standards for
Hospital Function Evaluation (Version 5.0) indicated an “Entire building smoke-free” policy.
Accordingly, since “Smoker separation” does no longer conform to the demands of the time,
the statement was revised in 2004 to “promote a smoke-free environment.”

Japanese Nursing Association declared its commitment to implement
actions for tobacco use of nurses in 1999, and followed it up by
identifying the current state and issues concerning tobacco use
among nurses and formulated the basic approach to future actions
and an action plan. JNA then started its actions to reduce thesmoking rate among nurses in 2001, in collaboration with theprefectural nursing associations, and also declared the “Actions for
tobacco use statement.” JNA has implemented various proactive
actions in accordance with the statement.

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Nurses’ action plan for tobacco use(2004 – 2006)
Targets: 1) Nurses and nursing students; 2) Nursing
management divisions at health and/or welfare facilities
and teaching staff at nursing educational institutions; 3)
Prefectural nursing associations; and 4) Japanese Nursing
Association
Planned period: 2004 – 2006 (3 years)
Goal: To halve nurses’ smoking rate from the 25.7% in2001 by 2006
In 2004, JNA published, “Nurses’ action plan for smoking cessation 2004,”
which included the “Nurses’ action plan for tobacco use” and the“Smoking cessation support guide for nurses.”
The “Nurses’ action plan for tobacco use” presented clear goal and anaction plan for the three-year period from 2004 to 2006. The four-item of
the “Action for tobacco use statement” published in 2001 provided thefundamental policy, each of which had a set achievement objective. In
addition, per objectives, JNA indicated action plans for each four target
groups. The goal was to halve the smoking rate among nurses (in 2001 it
was 25.7%) by 2006 to be the same as the rate among adult females in thegeneral population, and to eliminate nurses’ smoking at work.
Result of the actions: though the 2006 survey noted that the objective tohalve nurses smoking rate was not attained, the smoking rate had
declined.

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Smoking cessation support guide fornurses
Chapter 1: Understanding the characteristics of nurses who smokeand examine how to support behavior changes to stop smoking
Chapter 2: Examine methodologies to support nurses who smoke
to change their behavior to stop smoking
Chapter 3: Examine to develop a working environment that
supports nurses’ smoking cessation
Chapter 4: JNA role in promoting smoking cessation among nurses
In the “Nurses’ action plan for smoking cessation 2004,” not only “Nurses
action plan for tobacco use,” but also “Smoking cessation support guide fornurses” were published.
This guide discussed the behavior of nurses who smoke and their
psychological characteristics, and presented a review summary of how to
support their smoking cessation.
The questionnaire survey was conducted with the aim of understanding thecharacteristics of nurses who smoke, and found the following: 1) compared tofemales in the general population, female nurses smoked twice as much, andtheir smoking rate did not decline with age; 2) the smoking rate varied widely
depending on their general education history, specialized education history,
professions and workplaces; 3) nicotine dependency of female nurses was notparticularly higher than that in the general female population; 4) overall levelof knowledge about tobacco was low; and 5) despite being in a profession ofwhich it is expected not to smoke, their workplace environment
accommodated smoking. In addition, an interview survey found that nurses
adapted to the smoke-free hospital environment by binge-smoking before andafter work and during breaks. These findings clearly showed that it is not only
important to educate individuals about tobacco, but also to take action to
make the entire workplace smoke-free.
This guide does not only review how to support individuals, but also multiangled approaches to the workplace environment and the role of JNA.
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Enlightenment activities
Nurses and tobacco
Nurses and tobacco

A pamphlet and poster were created as a part of enlightenment
activities of the action for tobacco use.
The pamphlet “Nurses and tobacco” was created in 2003 for an antismoke campaign aiming to educate nurses and spread the message.
Based on the findings of the 2001 “Nurses and tobacco use, actual
situation survey”, the campaign provided basic knowledge about
tobacco and smoking cessation. The pamphlet also introduced thewinners of the “Smoking cessation catch copy competition” that washeld in 2002 as part of the enlightenment activity to show nurses what
expectation public have of them.
This pamphlet was distributed at facilities where JNA members work,
educational institutions, prefectural nursing associations and otherplaces, as well as utilized during nurses’ orientation when they start a
new career and nursing students’ orientation when they start theircourse.
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Enlightenment activities
PamphletA smoke cessation support pamphlet was created in 2005 to coincidewith the WHO Framework Convention on Tobacco Control that comeinto force. This pamphlet was aimed to support individual nurses’ efforts
to stop smoking (especially female nurses in their 20s and 30s.)
The pamphlet not only reiterates the impact of smoking on femalespecific diseases and beauty aspects, but also addresses the stressmanagement perspective, often mentioned by nurses as the reason why
they smoke.
The pamphlet also has checklist and chart to understand one’s own
smoking pattern and smoker type, designed to raise smoke cessation
awareness by letting the nurses fill it out themselves.
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Survey of actual situation of
tobacco use among nurses
Nurses smoking rate
Total (N = 3,483)

7.9

Male (N = 122)

Female (N = 3,344)

15.4

74.7

29.5

7.2

0%
Currently smoke

26.2

40.2

15.1

10%

20%

2

4.1

75.8

30%

40%

Smoked in past

50%

60%

1.9

70%

No habitual smoking

80%

90% 100%

No answer

Source: Japanese Nursing Association2013 Survey of actual situation of tobacco use among nurses

In addition to enlightenment activity of action for tobacco use, JNA
conducted, a survey of actual situation of tobacco use among nurses in
2001, 2006 and 2013. The 2013 survey found that nurses’ smoking rate
for males and females was lower than the national smoking rate (male:
34.1% and female: 9.0% 1))
1) MHLW, 2012 National Health and Nutrition Survey

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Survey of actual situation of tobacco
use among nurses
Awareness of health impact of smoking (multiple answers) (N = 3,483)
97.7
91.1

Lung cancer
AsthmaBronchitis

Emphysema

62.8

Myocardial infarction

81.5
81.5
76.4
74.4
82.4
81.3

52

Atherosclerosis

72.4

43.6

Aneurysm

22.6

32.7

Laryngeal cancer

72

43.4

Esophageal cancer
Stomach ulcers

22.6

Stomach cancer

39

25.5
18.9
13.4

Buerger’s disease

Subarachnoid hemorrhage

22.8
19.3
15.4

Liver cancer
Infertility

27.6

Periodontal diseases

57.9

34.2
35.6

35.8
36.2
48.3

22.4

Effects on pregnancy

78.8

87.9

12.3
16.7

Infant otitis media
Sudden infant death syndrome (SIDS)
Perinatal deaths

37.2
0

10

Smoking

20

30

50.7
50.6
45
40

Passive smoking

50

60

70

80

90

100

Concerning the risks of smoking, 70–90% of respondents were aware of the risks oflung cancer, asthma, bronchitis, and such respiratory diseases, laryngeal cancer andthe impact on pregnancy. However, fewer were aware of the risks for aneurysm,
stomach ulcers and stomach cancer.
Concerning the risks of passive smoking, 60–90% were aware of the risks of lungcancer, asthma, bronchitis and such respiratory diseases, while fewer than half knew
about laryngeal cancer, atherosclerosis, stomach ulcer and periodontal diseases.
Japanese Nursing Association(%)

Source: Japanese Nursing Association2013 Survey of actual situation of tobacco
use among nurses

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Future actions
1.

2.

3.

4.
5.

By ensuring that all nurses have the accurate knowledge
about health effects of tobacco, also to protect nonsmokers from passive smoking, JNA aims to achieve zero
smoking among nurses.
JNA will provide enlightenment and promote the needfor smoking cessation support and promote appropriate
smoking cessation treatment for nicotine-dependent
persons.
JNA will further promote the education for nursing
students not to start smoking and to stop smoking.
JNA will realize adherence to smoke-free measures at
hospitals, clinics and other public spaces.
JNA will disseminate the necessary information to all
nurses for a smoke-free society.

Following up the findings of the 2013 Survey of actual situation of
tobacco use among nurses, JNA will strive to lower nurses’ smoking rateand continue its actions as a professional organization of nurses who
support health of public to ensure that nurses learn the accurate
knowledge about smoking and to realize a smoke-free society.

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In Conclusion
As the Government of Japan proceeds with its community
based integrated care system, emphasis has been placedon the community as a living place. JNA’s focus is onbuilding a system that supports people in the community
to live long healthy lives through such measures as theprevention of lifestyle-related diseases.
With regard to the prevention of lifestyle-relateddiseases, JNA will make a contribution by enhancing thefoundation of PHN activities, which are intended ashealth promotion activities for community.
Meanwhile, JNA aspires to achieve a society free of
tobacco, one of the most serious risk factors for lifestylerelated diseases, by promoting accurate knowledge about
tobacco among nurses.

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