J Phys Fitness Sports Med, 6 (1): 49-57 (2017)
DOI: 10.7600/jpfsm.6.49

JPFSM: Study Protocol

Study protocol and overview of the Kasama Study: Creating a comprehensive,community-based system for preventive nursing care and supporting successful aging
Tomohiro Okura1*, Taishi Tsuji2, Kenji Tsunoda3, Naruki Kitano4, Ji-Yeong Yoon1, Mahshid Saghazadeh1,
Yuki Soma5, Jieun Yoon1, Mijin Kim6, Takashi Jindo4, Shaoshuai Shen6, Takumi Abe6,7, Ayane Sato6,
Shoko Kunika6, Keisuke Fujii6, Haruka Sugahara8, Miki Yano8 and Yasuhiro Mitsuishi91

Faculty of Health and Sport Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan
Center for Preventive Medical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba 260-8560, Japan
3
Faculty of Social Welfare, Yamaguchi Prefectural University, 3-2-1 Sakurabatake, Yamaguchi, Yamaguchi 753-8502, Japan4
Physical Fitness Research Institute, Meiji Yasuda Life Foundation of Health and Welfare, 150 Tobuki, Hachioji, Tokyo 1920001, Japan
5
Department of Social Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
6
Doctoral Program in Physical Education, Health and Sport Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki
305-8577, Japan
7
Japan Society for the Promotion of Science, Kojimachi Business Center Building, 5-3-1 Kojimachi, Chiyoda-ku, Tokyo 1020083, Japan
8
Master's Program in Health and Sport Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan
9
Kasama City, 3-2-1 Chuo, Kasama, Ibaraki 309-1792, Japan
2

Received: October 25, 2016 / Accepted: November 11, 2016

Abstract This study protocol introduces the Kasama Study, a mid-sized longitudinal study ofhealth, fitness, and physical activity in older people. The study is a challenging research projectthat discusses the future of the system for preventive nursing care and for supporting successful
aging in Japan. In May 2008, we began the Kasama Study with an exercise program of preventive nursing care for community-dwelling older adults. As of March 2016, we have conducted
six study projects: 1) the Kasama health checkup for longevity, 2) an all-round exercise class, 3)
the volunteer and the circle, 4) an exercise class for men only, 5) an exercise class for improving cognitive and physical function, and 6) the Kasama Iki-iki checklist survey. We describe
each project in detail in the present study protocol.
Keywords : Kasama Study, community-dwelling older adults, community-based intervention,community-based health promotion

What is the Kasama Study?
Launched at Kasama City, Ibaraki Prefecture, Japan, in
May 2008, the Kasama Study is a mid-sized longitudinal
study of health, fitness, and physical activity in older
people. The study aims to create a comprehensive, community-based system for preventive nursing care and supporting successful aging (Fig. 1). In addition to research,
it has been acknowledged that local communities requiresocial contribution activities conducted by universities,
including providing instructions for a variety of exercise
trainings for successful aging. Therefore, the Kasama
Study can be characterized as a field of practice in which
not only research, but also education and social contribution activities are simultaneously conducted.
Before beginning the Kasama Study, the authors il*Correspondence: okura@taiiku.tsukuba.ac.jp

lustrated Fig. 2 to explain the hypotheses that the study
should demonstrate. Certainly, the study’s ultimate goal
is to extend healthy life expectancy, which is clearly influenced not only by medical variables, but also by physical, psychological, and cognitive functions. For example,
higher levels of walking ability and lower extremity
muscle function are undoubtedly associated with a longer
healthy life expectancy. To provide a hypothetical example, we ask how an individual can acquire higher-level
physical functions. The answer may be by maintaining ahigh level of physical activity by frequently going outdoors, at least for the last few years. We can also ask howthat individual is able to maintain a higher level of physical activity. The answer may be because the person has
had many chances to travel, shop, engage in hobbies, andattend various volunteer activities. Furthermore, that individual may have been active because he/she is a sociable
person, i.e., maintains a high level of interpersonal inter-

JPFSM : Okura T, et al.

50

Comprehensive,
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Fig. 1

Logo of Kasama Study

Figure 1. Logo of Kasama Study

Healthy life expectancy

Sense of coherence

Walking ability
lower extremity muscle function

Physical activity
and participation

Body functions andbody structures:pain, voice, speech,functions on internal
medicine and surgery

Social support
Social network: interpersonal interactions and relationships

Major life areas: education, work an
and employment, and economic life
Geographic environment and social capital
Figure 2. Pathways of physical, psychological, and social factors in
relationto healthy
life
expectancy
Fig.
2 Pathwaysof physical,
psychological,
and social factors in relation to healthy life expectancy

actions and relationships. The above description, however, has focused only on personal factors, but investigating
the relationship of health and fitness with environmental
factors, such as the geographical environment and social
capital, is also necessary.
The Kasama Study is a challenging research projectthat tests the above hypotheses comprehensively by having young researchers, many under 30 years of age, conduct various types of surveys based on their individual
research themes that are in accordance with the Kasama
Study’s goals. In this review, therefore, we describe thedetails of the study protocol and provide an overview ofthe Kasama Study. This series of studies was conductedwith the approval of the ethics committee of the University of Tsukuba (Tai 21-25 and Tai 23-36).

Environmental factors

Services, systems, and policies

Psychosocial
factors

Psychological factors

Personal factors Fundamental factors

Mental function:
Subjective sense ofwell-being, depression,
self-efficacy

Physical fitness

Physical factors

ICF

Cognitivefunction

Kasama City profile
Kasama City is a relatively small city located in thecentral region of Ibaraki Prefecture, Japan. As of April
2016, its population was 77,719. Kasama City’s aging rate
(percentage of the population that is ≥65 years of age) is
28.4%1), slightly higher than that of the Japanese national
average (26.8% as of December 2015)2). In March 2006,
the city merged three municipalities: Kasama City (former), Tomobe Town, and Iwama Town. Kasama City’s
total area is approximately 240 km2, approximately 20 km
north to south and approximately 19 km east to west. A
series of hills or mountains (Mt. Yamizo) is located in thenorthwest region, and Mt. Atago is located in the southwest region. A flat plateau spreads southeast from thenorthwest, and the Konuma River flows through the city

JPFSM : Study protocol of the “Kasama Study”

center from northwest to east.
Kasama City is known for primary industries because
forests and farms occupy more than 60% of the city’s
area3), and primary industry workers constitute 5.4% of
the population3) (national average, 4.2%)4). In addition,
the city has an attractive sightseeing location, Kasamainari-Jinja Shrine, and the well-known ceramic warecalled Kasama-yaki also attracts tourists. In recent years,
urbanization has advanced owing to convenient transportation (trains and motorways), the building of housing
estates, and the existence of a neighboring city, Mito City,
the prefectural capital. Kasama City conducts various activities and services for health care and considers the promotion of its citizens’ health an important task. For thatreason, in 2012, the city initiated a project called Healthy
City Kasama Declaration5).
Progress of the Kasama StudyIn May 2008, we began the Kasama Study with an exercise program of preventive nursing care for communitydwelling older adults (all-round exercise class). To date(March 2015), we conducted six study projects: 1) the
Kasama health checkup for longevity, 2) an all-round exercise class, 3) the volunteer and the circle, 4) an exerciseclass for men only, 5) an exercise class for improving
cognitive and physical function, and 6) the Kasama Ikiiki checklist survey. Fig. 3 shows the Kasama Study’s
progress and the number of participants in each project.
After the second all-round exercise class was completed,the circle was initiated according to the wishes of theparticipants who completed the class. In 2009, to supportand develop the activities of the circle, we began a project
for training volunteers who have skills to manage circles
and provide exercise instruction. Additionally, we haveconducted health checkups for the circles’ volunteers andparticipants every year since 2009. In 2009, we also held
the first annual Kasama health checkup for longevity. We
initiated three projects in 2013: an exercise class targeting only middle-aged and older men, an exercise class for
improving cognitive and physical function aimed at developing a novel exercise program for persons with mild
cognitive impairment, and the Kasama Iki-iki checklist
survey in conjunction with a municipal screening projectfor pre-frail older adults. We describe each project in detail in this chapter’s subsequent sections.
Annual follow-up study on the Kasama health checkup
for longevity
The Kasama health checkup for longevity is an open cohort study begun in 2009. The cohort’s participants consist of people aged 65 to 85 years, randomly drawn fromthe Basic Resident Registration Network System, or “JukiNet”. The cohort study’s examinations serve as a baseline, and follow-up surveys are conducted annually from51

July to August. As baseline subjects, we selected 213
participants from 1200 randomly drawn people in 2009,183 participants from 900 drawn people in 2010, 174 participants from 900 drawn people in 2011, 118 participantsfrom 800 drawn in 2012, and 71 participants from 400
drawn in 2015. In total, 759 baseline participants (18.1%)
from 4200 were drawn from the 2009 to 2012 and 2015
surveys. For the 2013 and 2014 surveys, only follow-up
examinations were conducted.
In these checkups, the main variables include physical performance 6-15), physical activity 6,9,16-22), cognitive
function11), foot posture10,15), psychological status17,19,21-24),
sleep status19,20), and social networks17,22,23) (Table 1). Additionally, objectively-built environmental attributes wereassessed using a geographic information system25,26). Although the sample size of this cohort study is smaller thanother relevant cohort studies, this study has the advantage
of assessing various physical performance tests including
reaction time9), postural sway10,15), ground reaction force
in sit-to-stand movement7,13), and cognitive function11).
The information obtained has been used as control data
for all-round exercise classes and voluntary group exercise activities27) in addition to regular cross-sectional andlongitudinal studies.
Summary of the all-round exercise class
The all-round exercise class is a daycare physicalstrength program that began in May 2008. Its purpose isto improve physical and cognitive functions and mental
health and to prevent falls in older adults. The class, offered three times a year, is held once a week for 11 weeks,and consists of a 90-minute exercise program and a
30-minute lecture about health. Participants live independently and are aged 65 or older, including people with ahigh risk of future decline in basic or advanced activities
of daily living. Participants were recruited through local
advertisements or invited by municipal employees. The
exercise program consists of a warm-up activity for 15
minutes, square-stepping exercise (SSE)28) for 40 minutes,
a recreational activity for 20 minutes, and a cool-down
period for 15 minutes. SSE is performed on a thin felt mat(250 × 100 cm) divided into 40 small squares (25 × 25cm). The exercise technique includes forward, backward,
lateral, and oblique steps, with step patterns progressively
becoming more complex. A previous study showed that
SSE improves physical and cognitive functions29,30) andreduces the risk of falling31). In April 2013, we added resistance training called brown rice dumbbell exercises32)
and the Locomo exercise33). We evaluated physical fitness34,35), physical activity34,35), cognitive function36), depression37), and social networks37) at baseline and after the
program (Table 1).

Kasama Iki-iki Checklist survey

Exercise Class for Improving in
Cognitive and Physical Function

Exercise Class for Men Only

Health check-up for participants ofthe voluntary group exercise

Voluntary group exercise activities

SSE elderly leadership training
seminarAll-round exercise class (Exercise
program for preventive nursing
care)

Kasama Health Checkup for longevity(Prospective cohort study)

Projects

Figure 3. Flow of Kasama Study

2008

2009

2010

2011

2012

2013

2014

2015

2016

2nd
N = 20People who finish
the exercise
program take partin the activity.

1st class
N = 106th
N = 207th
N = 208th
N = 199th
N = 1910th
N = 1311th
N = 2613th
16th
N = 16N = 2712th
14th N = 21N=915th N = 9

2nd
N = 173rd
N = 224th
5th
N = 19 N = 16

Volunteers who completed the seminar manage the voluntary group exercise activity.

1st seminar
N = 16

1st check-up
N = 202nd
N = 963rd
N = 115

Volunteers and participants of the voluntary group exercise activity take part in the check-4th
N = 204

1st survey
N = 10339

1st class
N=7
2nd
N = 2020

2nd
N = 21

6th
N = 279

2nd
N = 21

3rd
N = 187th
N = 315

3rd
N = 1427th N = 17
28th N = 13

26th N = 15

7th survey
Follow-up from 1st = 31
Follow-up from 2nd = 45
Follow-up from 3rd = 47
Follow-up from 4th = 43
Newly enrolled number = 68

12th 13th
N = 27 N = 23

24th N = 2125th N = 21

23rd N = 11

6th survey
Follow-up from 1st = 45
Follow-up from 2nd = 51
Follow-up from 3rd = 50
Follow-up from 4th = 4910th 11th
N = 19 N = 23

21st N = 23
22nd N = 14

20th N = 24

9th
N = 20

1st class
N = 165th
N = 2108th
N = 1618th N = 13
19th N = 16

17th N = 15

6th7th
N = 20 N = 15

People who finish the exercise program or participants of the voluntary group exercise activity take part in the

4th
N = 165th
N = 29Held in Kasama City 䠄As at January 2015, there are 25 groups holding the activity and 625 people belong to those activities䠅

3rd
N = 20

1st survey
2nd survey
3rd survey
4th survey
5th survey
Newly enrolled number = 213 Follow-up from 1st = 87
Follow-up from 1st = 61
Follow-up from 1st = 53
Follow-up from 1st = 57
Newly enrolled number = 183 Follow-up from 2nd = 66
Follow-up from 2nd = 59
Follow-up from 2nd = 49
Newly enrolled number = 174 Follow-up from 3rd = 74
Follow-up from 3rd = 65
Newly enrolled number = 118 Follow-up from 4th = 52

4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3

Fig. 3 Flow of Kasama Study

52
JPFSM : Okura T, et al.

Table 1. Measures included in the six study projects(activities of daily living, physical strength, nutritional status, oral function, houseboundness, cognitive function,
depression risk)
Others(sleep, subjective health, the distance to the location where you want to go from home, participation in community
activity, subjective measures of the built environment awareness of preventive care exercises, life-space and mainmode of transportation, presence of exercise companions, presence of someone to talk to)

Physical performance tests
A) Grip strength (muscle strength)B) Single-leg balance with eyes open (balance)C) Functional reach (balance)D) Sit-and-reach (flexibility)E) Standing time from a long-sitting position (lower extremity function)F) 5-time sit-to-stand (lower extremity function)G) Ground reaction force in a sit-to-stand (lower extremity function)H) Timed up and go (lower extremity function)I) 5-m habitual walk (lower extremity function)J) Hand working with pegboard (hand dexterity)K) Trail making peg test (hand dexterity)L) Simple reaction time (reaction speed)M) 4-way choice reaction time (reaction speed)N) Hand-held dynamometer (lower extremity strength)O) Arm curl (upper extremity strength)
Body characteristics
䞉Bioelectrical impedance analysis (body composition)
䞉Foot posture (foot deformity)
Frailty䞉Kihon Checklist

Psychological status
䞉Geriatric Depression Scale䞉Sense of Coherence Scale䞉Generalized Self-Efficacy Scale
Social networks
䞉Lubben Social Network Scale(family networks, friends networks, interdependent social supports, living arrangements)
䞉Lubben Social Network Scale - 6(family networks, friends networks)(sleep quality, sleep latency, sleep duration, sleep duration, habitual sleep efficiency, sleep disturbances, use of
sleeping medication, daytime dysfunction)

Cognitive functions
䞉Five-cognitive function test
(verbal memory, attention, word fluency, visuospatial cognition, associate learning)
Physical activity
䞉Physical Activity Scale for the Elderly(leisure-time physical activity, household physical activity, work physical activity)
䞉IPAQ-Short(walking, moderate-intensity PA, vigorous-intensity PA)
䞉Sedentary behavior(watch television, use of computer)䞉Pedometer, accelerometer(daily step counts, physical activity)
Sleep䡡Pittsburgh Sleep Quality Index

Instruments (domains)

Table 1. Measures included in the six study projects

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Checklist survey

41)

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Ref.

JPFSM : Study protocol of the “Kasama Study”
53

54

JPFSM : Okura T, et al.

Summary of voluntary group exercise activities andtraining volunteers for instructing SSE
We have held SSE elderly leadership training seminars
since September 2009 to train elderly volunteers, called
SSE leaders, who manage voluntary group exercise activities; they provide technical and emotional support forcommunity-dwelling elderly to engage in SSE 27). One
course is comprised of weekly training seminars over a
period of 5 weeks. Each seminar lasts 120 minutes, andtwo courses are held each year. Training seminars consistof lectures and practical training for instructing and supporting exercise and discussions about ideal volunteer activities or instructing SSE. Participants who complete an
SSE course receive certification as an SSE leader. Up tothe time of this writing, we have trained 253 volunteers.
In Kasama City, voluntary group exercise activities withthe primary purpose of practicing SSE are held either two
or four times a month for 90–120 minutes per session
at communal facilities such as community centers andgymnasiums. Trained volunteers manage the sessions.
In 2016, 32 groups held sessions, and 702 communitydwelling older people, including 193 volunteers, participated in these sessions. Once a year since 2010, we haveconducted health checkups for these participants andinvestigated the effects of exercise activities on general
health (e.g., physical and cognitive functions, physicalactivity, depression, and social networks). Since 2010,
seminars for upgrading volunteer skills have been held tohelp volunteers improve their ability to instruct and support exercise.
Summary of the exercise class for men only
Exercise classes, held by municipalities in preventive
nursing care for older adults, aim to improve locomotor
function. Since the majority of participants are female,in most cases, considering methods to encourage greater
participation among males is vital. From our experiencein outreach activities, we inferred that gender differences
exist for purposes of exercise practice. Male participation
would likely increase if men-only classes were provided.
Thus, since June 2013, we have held a daycare programfor improving locomotor function aimed only at men. We
offer 90-minute sessions conducted once a week for 11
weeks. Municipal employees recruit older men possibly
needing long-term care by approaching them directly or
by distributing public relations brochures. The exercise
program comprises brown rice dumbbell exercises32)(strength training) as a main exercise, recreation, and SSE(aerobic exercise). Brown rice dumbbell exercises requireparticipants to use “dumbbells” that are made of 300 g ofunpolished rice sewn into cotton cloth. There are 12 typesof strength exercises that aim to improve muscular function of the entire body, and participants perform 10 to 15
repetitions of each exercise. These exercises are reputed

to maintain participant life-activity capacity. Additionally,
since June 2014, a 15-minute lecture on health has been
included.
Summary of the exercise class for improving cognitiveand physical function
An exercise class for improving cognitive and physicalfunction has been conducted on a trial basis to develop
a novel preventive care program for older adults withcognitive decline. This class focuses on dementia prevention, and therefore, its characteristics differ from those of
the all-round exercise class. Two intervention programs
were offered once a week, for a 5-week period in 2013,
and for an 11-week period since 2014. Each session lasts
120 minutes, including warm-up (10 minutes), dual task
training (combination of aerobic exercise and cognitive
task [15 minutes], e.g., calculation while walking), SSE(40 minutes), recreation for facilitating participants’ communication (15 minutes), brown rice dumbbell exercises(resistance training, 20 minutes), and cool-down (10minutes). The main measured variables were cognitive
function, physical function, mental state, social network,and self-efficacy (Table 1). Based on the results of the
Kasama health checkup for longevity, we encouraged
older adults with reduced cognitive function to participate
in the program. Additionally, older adults with very mild
cognitive decline or without cognitive decline were also
permitted to join when there were few participants since
this program was a trial.
The advantage of this intervention program is adopting
multiple exercises effective for cognitive function38,39), forexample, SSE, resistance training, and dual task training.
Furthermore, because mental state is an important factor
in dementia prevention40), this program includes recreation to improve participant mental state (depression andself-efficacy).
Summary of the Kasama Iki-iki checklist survey
The Kasama Iki-iki checklist is an inventory survey for
Kasama City residents aged 65 years and older who havenot been certified as needing care. This self-administeredmail survey evaluates the general health and living environment of older adults, and then early intervention
is conducted to prevent the need for long-term care. In
2013, we sent a questionnaire to 16,870 older people
who live in Kasama City, and received 10,339 responses(61.3% response rate). In 2014, the survey was administered to 3549 older people who live in the Iwama area,a part of Kasama City. We received responses from2020 older people (56.9% response rate). We evaluateddemographic characteristics (e.g., age, gender, living arrangements, education, economic status, and clinical history), risk for long-term care (e.g., physical and cognitive
functions and depression) using the Kihon checklist41),

JPFSM : Study protocol of the “Kasama Study”

sleep, physical activity, neighborhood environment, andparticipation and/or awareness of Kasama City’s groupexercise activities (Table 1). If any data were incompletewith respect to demographic characteristics or the Kihon
checklist, we conducted a follow-up telephone survey. As
previously described, we conducted the Kasama healthcheckup for longevity, including comprehensive measurements such as physical and cognitive functions (measured
by objective methods), psychological status, and social
networks17,22,23). Connecting data from the Kasama healthcheckup for longevity to the Kasama Iki-iki Checklist survey makes it possible to obtain more objective and varied
information on participant health status.
Conclusion
The Kasama Study has been trying to address pioneering challenges that affect the future of preventive nursing care and for supporting successful aging in Japan.
Since 2008, evaluating the Kasama Study has produced
seven doctorate degrees and 15 master’s degrees, and 34
original articles have been published, thus indicating thestudy’s academic value. Simultaneously, however, because only one small laboratory conducts this study, theauthors must recognize some of its weak points, including
less research funding and a shortage of human resources
compared with representative Japanese cohort studies, forexample, the Hisayama Study by Kyusyu University, theLongitudinal Study of Aging by the National Institute forLongevity Sciences, and the Kusatsu Study by the Tokyo
Metropolitan Institute of Gerontology.
Details of the Kasama Study’s research outcomes will
be introduced in another report in which young researchers briefly describe new findings that are in accordancewith the Kasama Study’s final goals.
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this article.
Acknowledgments
When the Kasama Study was initiated, the experiences, skills,
knowledge, and philosophy provided by four experts was a considerable contribution to creating its mission. First of all, Dr.
Kiyoji Tanaka, a professor at the University of Tsukuba, gave
invaluable academic and health promotion training. Secondly,
Dr. Hiroshi Shimokata, a professor at Nagoya University of Arts
and Sciences, provided epidemiological guidance. Dr. Hunkyung
Kim, a leader at the Tokyo Metropolitan Institute of Gerontology,
advised in detail how to conduct an interventional study, and Dr.
Toshiaki Muraki, a professor emeritus at Ibaraki Prefectural University of Health Sciences, initiated the person-centered approachas crucial for health promotion. Dr. Muraki’s contribution wascentral to the mission of the Kasama Study. Also, the Kasama
Study could not have been established and continued for so many55

years without the deep understanding of Kasama City’s mayor
and collaboration with its administrative officers. We thank themfor their significant efforts.
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