This study analyzed contextual barriers and facilitators in the implementation of Strengthening Families Program (SFP 10–14), Brazilian version, a family-based preventive program focused on the prevention of risk behaviors for adolescent health. SFP 10–14 was implemented between 2016 and 2017 for socioeconomically vulnerable families in four Northeast Brazilian states as a tool of the National Drug Policy. A retrospective qualitative study was carried out in which 26 implementation agents participated. Data from 16 individual interviews and two group interviews were analyzed through content analysis. The most recurrent barriers were the group facilitators’ working conditions, weak municipal administration, precarious infrastructure, inadequate group facilitator training methodologies, low adherence of managers and professionals, and funding scarcity. The conditions highlighted as favorable to the implementation were proper intersectoral coordination, engagement of involved actors, awareness of public agency administrators, municipal management efficacy, and efficient family recruitment strategies. Favorable political contexts, engagement of implementation agents, and intersectoral implementation strategies were identified as central to the success of the implementation of SFP 10–14, especially in the adoption of the intervention, community mobilization, and intervention delivery stages. Further studies should combine contexts, mechanisms, and results for a broad understanding of the effectiveness of this intervention in the public sector. The health of Brazilian adolescents has deteriorated in recent years according to several indicators. Findings from three editions of the National School Health Survey  indicated an increase in tobacco-related product consumption (from 7.6% to 9%); fights involving a firearm (from 4% to 5.6%) or cold weapon (from 6.1% to 8.2%); unauthorized driving of motor vehicles (from 18.5% to 24.8%); and less frequent use of condoms in first intercourse (from 75.9% to 66.2%) , what facilitated the process and what were the barriers?” The second question was: “Regarding the local coordination of the SFP 10–14 in [name of the city where the participant worked], what facilitated the process and what were the barriers?” and so forth. An interview guide based on SFP 10–14 action theory in Brazil was used to conduct the interviews and focus groups. The action theory is conceptually defined as the program’s theory of change and seeks to explain the causal implementation mechanisms . Thus, aSFP 10–14 comprises seven two-hour long weekly sessions and four booster sessions, with the participation of children and adolescents 10 to 14 years old and their parents and/or legal guardians. In the first hour, children/adolescents and parents attend separate meetings and participate in age-appropriate activities. The modules for children/adolescents aim to improve self-efficacy in dealing with stress and peer pressure. The modules for parents stimulate the development of an authoritative parenting style, matching high levels of demandingness (control and supervision) and positive affect (involvement and warmth). In the second hour, the families reunite, and the activities address communication patterns and strengthening of family cohesion .SPF 10–14 has an implementation manual, translated and adapted for Brazil . The proBoth individual and group interviews were carried out by trained researchers. The researchers contacted all participants by telephone, between one and three months after the implementation of SFP 10–14, and presented the study objective, the expected length of the activity, the confidentiality of information, and the voluntary nature of participating in the study. At the convenience of the participants, it was agreed to conduct the interview individually or in groups. The individual interviews were conducted by telephone. An image in PDF was sent via email with the seven stages of the SFP 10–14 action theory, described in Content analysis combining inductive and deductive categorization with frequency counting of categories was performed. This content analysis modality was chosen because it allows organizing the data with and without previous categories, in order to accommodate the richness of the data and, also, for allowing to compare the magnitude or relevance of the categories, based on their numerical expression. Firstly, preexploration of the transcribed material was carried out through floating readings of the interviews corpus. The objective of this stage was to select units of analysis that answered the research question. After analyzing 18 transcriptions (16 interviews and two group interviews), a total of 448 analysis units were obtained. Secondly, themes were identified and defined inductively, according to the categories developed for this study . These cCategorization of the data was performed by independent coders, who had had expertise in process evaluation methods of health interventions. All the categories found were revised twice. Initially, revision was done by the first author who categorized it, correcting any mistakes of synthesis and categorization; and then by the third author, for a second verification and correction of mistakes and biases in data interpretation. Disagreements among the coders were solved by the second author, who acted as a judge. Member checking was used to assess the data reliability. The category system was discussed with the group facilitators from the four states, who assessed the credibility and accuracy of the categories and subcategories. No divergence was detected. All data was imported into NVivo11.0. The categories with frequency lower than three reports were suppressed.The results indicate a slightly higher number of barriers than facilitators. Out of the 448 units of analysis identified in the implementation process of SFP 10–14, 234 were barriers (52%) and 214 facilitators (48%). The greatest obstacles described regarded municipality management, public agency administrators’ awareness and intersectorality. Reports noted that the administration was not proactive in facilitating the program adoption and delivery process, for example: (i) bureaucracies for releasing professionals (to work in the implementation), for public service exam authorization, and for supplying transportation to operationalize the distribution of snacks; (ii) lack of knowledge about local context on the part of managers; (iii) difficulties in managing intersectoral policies before the adoption of SFP 10–14; (iv) delays in the payment of professionals; and (v) difficulties integrating SFP 10–14 actions into the SARC routine.Public agency administrators with low awareness acted as barriers because they did not promote the adoption of the prevention policy associated with SFP 10–14. Intersectorality was noticed as a barrier in two aspects: (i) when it did not exist, the lack hindered the implementation; and (ii) when it existed, however, the professionals listed difficulties in finding compatible schedules between the group facilitators from different services. SFP 10–14 implementation, which was intersectoral, demanded the existence of good coalitions between intersectoral networks. A report that exemplified the lack of awareness of public administration agents acting as a barrier was:“(…) there were other managers who had never participated in the process. “Oh, I agree”, but you agree and that is not the point. Perhaps some managers lacked commitment. As if it were “let the technicians take care of that”. And that doesn’t fulfill our needs, like a providing snacks, which depends on authorization from the top manager, that is hard to get. Since, we don’t often get it, everyone just do what they can.”A culture of prevention, awareness of public agency administrators, intersectorality, and professionals’ adherence were highlighted as facilitators of the negotiation between federal and municipal levels for the adoption of SFP 10–14 by municipalities. On a local level, prior existence of high-level managers and governmental institutions that understood prevention policies as a priority, facilitated the implementation of SFP 10–14, this being more often the case in the initial stage of its adoption. When the program was well-received by the public agency administrators starting with the negotiation stage, the subsequent stages were facilitated, leading to improved communication between these administrators and other professionals and simplifying group facilitators’ release for participating in the delivery of SFP 10–14. Previous experience with SFP 10–14 in other implementation cycles, or with other evidence-based programs, facilitated the professionals’ adherence to the program as well. Public agency administrators’ awareness was highlighted as a facilitating element. Its major recurrences were in the negotiation and mobilization stages. However, according to reports, the impact of public agency administrators’ awareness reverberated across all other stages. In addition, the existence of well-structured intersectoral coalitions was stressed as the most facilitative element of all. Intersectorality was highlighted in the phases of negotiation for local adoption of SFP 10–14 and session organization. Network coalitions allowed the exchange of materials and tools necessary for the program’s delivery, as did the offer of high-quality snacks. The sensitization of public administration agents and the intersectorality as facilitating elements can be seen in:“Receive support from top managements helps a lot. From the secretary, from the mayor, (…) if they are not at the forefront, they should endorse and designate people to take care of it. If technicians have this endorsement from higher managers, the program happens, if it doesn’t, it doesn’t happen. So, in departments where the manager was more committed, we managed to do everything more easily. In our case, it was easy, because the staff was really involved, both the manager and the local coordinator.”In the local coordination stage, municipal administration is again seen as the primary barrier. In addition to this, a lack of prevention culture and minimal assistance from the federal supervisors were likewise recurrent. The absence of a prevention culture had repercussions on the initial stages, from the decision not to adopt the program by public agencies administrators, through departments such as health and education declining the program, to the family recruitment stage. Furthermore, some professionals reported difficulties in spreading prevention ideals, because the daily routine was focused on urgent demands. The following report exemplifies the difficulty of professionals in understanding the objectives of the program, which theoretically are aligned with the prevention work carried out at SARC. “For the SFP 10–14 to enter the services, there was a great resistance from the equipment professionals themselves, because it was something new and people thought they were getting more work, a demand for more work. Even the staff from the Ministry  and National Drug Policy Secretary came to provide explanations about the program. We were called for meetings to understand a little more about this program and how it would be executed. So, it would have been nice if there were always conversations and dialogues between us and the secretariat regarding how the program would be executed.”Regarding facilitators, the proper choice of public services to offer the implementation deserves attention. Proper choices were a service in which all group facilitators are employees of that service and there is no need for displacement ; taking in account the available professionals’ abilities to deliver the program, such as group management experience; accessibility for families to the service where the program was delivered; and knowledge about community profile prior to site selection. The following report demonstrates how these agents’ awareness facilitated the planning at this stage. “In the municipalities that ran (the program) (...) we managed to set up good relationships with the secretaries that endorsed the local coordinator to execute and deliberate on the issue. So, it was not necessary to have to take all the information through the municipal secretary to do something, (...) received carte blanche to deliberate. (...) We believe that this was remarkably good.”Professionals’ poor working conditions were repeatedly cited as a barrier to service mobilization and echoed down to team training and SFP 10–14 delivery stages. Most cited were the professionals’ workload, due to participating in both the team training and program implementation; the low number of employees working in the services; and the need for many professionals for the implementation and a lack of time within the work day. Difficulties imposed by municipal management in service mobilization were also reported, such as not allowing the group facilitators to perform SFP 10–14 activities as a SARC routine and late payment.Failures were observed as well regarding the professionals’ awareness of the time requirements for participating in the training and implementing the program. Reports identified a lack of information about the true complexity of implementing SFP 10–14 before the professionals decided to participate in the program implementation team training. Managers confirmed that quitting was common during or shortly after completing it. This occurred because only during training did the professionals realize the incompatibility between the work necessary for program implementation and the work they already had. The following report points out reasons for the lack of adherence by professionals. “(…) because of the simultaneous activities we did not always have physical space available for the activities. We had to disturb the service dynamics to carry out the program, which we did, but we knew we were holding up routine activities. That is the reason why service providers are resistant to the program, and we understand it.”Public agencies administrators who had their awareness raised by the program’s arrival acted significantly by doing the same for the implementation professionals. The reduction of bureaucratic hurdles, a consequence of having aware managers, facilitated the engagement and adherence of professionals in the team training stage. The occurrence of this gradual awareness-raising, following the hierarchical flow of the service management was reported as a facilitator. This is not the only or the best way to communicate, it just portrays an effective communication channel in program implementation. Additionally, manager awareness eased the release of professionals to work on the program.Even though municipal management and intersectorality played mainly as barriers, they were also cast as facilitators. The existence of organized municipal management, prior to the program’s arrival, acted positively in its implementation. Such management included managing people in their activities, decentralizing power, and redirecting financial resources. The engagement of professionals acting as facilitators in this stage can be identified in:“In fact, the secretariat of health could not provide enough material necessary for executing the SFP 10–14, such as cardboards, to everyone. There is a list, from the three departments , that was shared to check what each department could provide. When they contributed, we put everything together and distributed it to the regions.”The selection of training methodology for the group facilitators, multipliers, and coordinators was a strategy that simultaneously helped and hindered program implementation. There were conflicting opinions among these agents regarding (i) the shortening of the training course from three to two days; and (ii) the inclusion of broader themes that discussed principles of prevention policies and evidence-based programs but would reduce the time for practicing the program activities to be offered. While for some interviewees the reduction in time made it difficult to understand the activities—as it was not possible to practice them—for others it made the training less tiresome and more productive. For some agents, the introduction of broader themes reduced the training time for the activities of the SFP 10–14, which hampered transporting knowledge acquired in training to the local reality and caused the perception that they were less prepared for adaptations at execution time. However, for others, the insertion and discussion of these themes were fruitful for understanding the program’s essence, which facilitated the necessary “in-flight” adaptations. The following report demonstrates the interviewees’ point of view, who would prefer a longer training:“It could be expanded (the training hours). It is because there are many activities to be developed and we do not see all the activities during training”.As previously discussed, the professionals’ working conditions also had a negative impact on team training, especially when it impeded participation in the training due to workload. The precariousness of the working conditions and low adherence of professionals and managers involved in the implementation were also listed as barriers in this stage.The methodologies used by federal educators in the group facilitator, multiplier, and coordinator training also deserve to be highlighted as facilitative. As an example, clear and attractive information transfer, which allowed understanding the program’s essence, even if the training did not go through all the activities proposed in the program guidebook, was cited. The following report illustrates how appropriate the methodology used was.“There was no way for her  to apply all the activities in the training. What was applied served us as starting point. I think that what was explained in the training was extremely important to guide us in adapting it in different scenarios.”Implementation strategies continue to play a fundamental role in the selection of families. Barriers in family selection and invitation have two primary sources: (i) families not meeting the program’s prerequisites, such as the ability to read and write and (ii) lack of clarity on the part of the federal supervisors regarding the target audience, consequently creating recruitment difficulties for the multipliers and group facilitators. Discrepancies were reported between the proposed target audience profile and that of the community, for example, being able to read and write or not already being a drug user. In addition, it was reported that group facilitators had difficulty denying participation to families already being assisted by a local service who did not meet all of the program’s prerequisites. The difficulty of recruiting the proper profile caused, according to the managers, disengagement by the professionals. This, along with the families’ incompatible schedule with the program’s, fed the barriers to family selection. The managers report that matching the community’s family profile to the choice of service to execute the program is necessary. If the community receiving SFP 10–14 is too precarious, or if the users of the services are already abusing alcohol and other drugs, then the professionals have a hard time selecting families. The following report describes the professionals’ difficulties in selecting families to participate in the program. “(…) we knew teenagers and children that we believed should be part of the SFP 10–14, but the program was really strict with the age limit. Leaving out a nine-year-old child or a fifteen-year-old teenager who wanted to participate was a problem, however they were technically ineligible and we couldn’t take them in.”Several strategies were used in the advertising to and selection of families. The most common were actively seeking families within the community; verifying that the families had the proper profile; advertising SFP 10–14 in a youth-attractive way; mentioning the snacks and freebies in the advertisement; word-of-mouth advertising by families who had participated in prior cycles; and inviting families individually rather than in groups. Using two or more of the cited strategies was common. Although the advertisement of SFP 10–14 by former participant families was not an approach foreseen by the group facilitators, it was considered a positive one.The strategies for retaining families, which as a consequence increased the families’ adherence to the program, also facilitated this stage. Examples of such strategies were: identifying what the families consider attractive in the program and highlighting these aspects to them in the family invitation and awareness meeting; weekly contact with the family, repeating the invitation before each meeting; in the invitation and awareness meeting, employing a methodology similar to that used in meetings and follow-ups for people with difficulty writing. Furthermore, the existence of a prior relationship between the service and the community facilitated family outreach and indicated greater engagement on their part. One of the family maintenance strategies used by professionals as a facilitating element can be seen in:“(...) in our group there were several mothers who couldn’t read or write. We were afraid that when we handed up the brochures, they would feel embarrassed. So, since the first meeting, we welcomed them warmly so that they would not feel that way for not being able to read.” Insufficient financial resources and infrastructure problems were the main obstacles in the stage of organizing the venues, group schedules, and materials. Common difficulties faced were the location’s room infrastructure and material resources being incompatible with SFP 10–14’s requests; unavailability of audio and video ; lack of a space for children under 10 years of age; rooms unavailable for the implementation, causing interruption of other activities of the service during program delivery and funding cuts for snacks. Another item that hampered implementation was the (in)compatibility of families’ schedules with the meeting schedule. Families preferred late afternoon meetings, which is the usual service closing time. The difficulty in finding schedule compatibility is evident in this comment:“(...) we initially thought and still think that there is a big issue with making workers’ schedules compatible with the families’ schedules for the program’s activities. We do not want to overwork our professionals. This remains a considerable barrier.”Planning prior to the program’s start was the most facilitating strategy in the organization stage. When well-executed, planning improved program delivery; the professionals reported feeling more prepared to handle the activities and more relaxed about the availability of the implementation material needed. Intersectorality was considered a facilitator in this stage as well. It is strongly related to the already-existing good coordination between the intersectoral networks, the quality of communication between the professionals, and their adherence to the program’s implementation. The municipalities where the networks coordinated to implement the program were able to overcome barriers due to infrastructure shortfalls, facilitating program organization. As an example, cars were used to transport audio and video equipment between services. The following report demonstrates how positive the engagement of professionals was in solving problems during the planning of the program.“(…) the team’s engagement was the main facilitator. No worker has ever been absent nor delayed. Besides, we talked about everything, if we identified a problem, we talked about it and got it solved.”The difficulties encountered in the initial stages had an impact throughout the program, up to and including the final stage of program delivery. Lack of engagement by managers, precarious working conditions of professionals, and methodological mistakes in training were the main barriers in SFP 10–14’s delivery.Precarious local infrastructure, low budget, and incompatibility between SFP 10–14 and the population attended by the service, with lower education levels, also had a negative impact on this stage. Such incompatibilities made it difficult to choose the participants and to engage them. The managers reported it was hard to carry out the weekly session planning since this activity requires the availability of transportation for the group facilitators (infrastructure), the release of professionals for this activity (adherence and awareness of management agents), and existence in the municipality of prior good communication between networks and professionals . Finally, they list, with less frequency, barriers resulting from the absence of a prevention culture and local strikes. The following report summarizes how the professionals’ precarious working conditions made this stage difficult.“It is too much (...) from a single sector . The program is too heavy for the service. This year we had a lot of work on trying to make the health department and the social assistance department work together. We hoped joining forces would make the implementation not so burdening. And it was not easy task, but we got more material and more human resources by bringing all departments together.”The perception of the effects on the families was an aspect understood only as a facilitator in the engagement of professionals. This means that the more families demonstrated the positive effects of the program or reported it, the more the professionals got involved in the program’s delivery, playing an ever more committed role. The following report exemplifies how the perception of the effects of SFP 10–14 on families was positive to engage professionals in its execution.“(...) speaking of my team, what convinced us during the meetings was really what the families were bringing to us as a result, strengthening their bonds, and we clearly saw that little by little it was happening. We saw that it was really working for the group. That is what convinced us. I speak for myself that I was very resistant after the first meeting, I was not very fond of the idea. I didn’t like being pushed to do this, but after the second and third meetings when we heard feedback from the families, and we started to get excited.”Despite reports of weak support from federal trainers, there was a greater frequency of reports affirming their presence and the benefits that came with it. This shows the importance of the weekly clarification of doubts that arose during the program delivery stage. In addition, the prior presence of high-level local managers and of governmental institutions that understood prevention policies as a priority facilitated the program implementation, which was more frequent in the initial stage of adoption and during the program’s execution. When receptiveness was present in the negotiation stage, the following stages were facilitated because of greater manager awareness, improving communication between them and the professionals and reducing hurdles to releasing the group facilitators. Furthermore, experience with SFP 10–14 in previous implementation cycles facilitated the professionals’ adherence to the program. The professionals’ joint operation was indicated as essential after having acquired experience with the program in previous years.The inductive and deductive systems of analysis were combined, and this process resulted in the categorization proposed in Data analysis according to the categories of the Context and Implementation of Complex Interventions model  is descrThe present study was guided by the following research question: how did the context influence the preimplementation and implementation of SFP 10–14 in Northeast Brazil? The analysis of interviews revealed a broad range of contextual factors that impeded and facilitated the implementation concentrated in the delivery, negotiation, and mobilization phases, with barriers having been reported slightly more than facilitators. The reports indicated that the SFP 10–14 implementation process was facilitated, primarily, when the implementation agents were engaged from the program’s adoption until its delivery and, secondarily, when the municipality, even a highly economically vulnerable one, was organized ahead of time to host the program, with appropriate infrastructure allocated, elevated planning capacity, and effective intersectoral coordination. This organization was enhanced in locations that had previously implemented policies of a preventive nature, such as the SFP 10–14 itself, or when the professionals and managers had chosen to incorporate prevention science and evidence-based science goals into practices.The findings point to the political context, the implementation strategies, and the implementation agents as having substantially impacted the implementation. As such, it should be noted that the majority of incentives considered helpful for the implementation involved better communication between the intersectoral networks, greater involvement of implementation agents in prevention policy and the program, and better understanding of the primary prevention objective and the intervention itself. These last aspects are consistent with findings of an evaluation of the SFP 10–14 implementation process in Wales, United Kingdom, which also identified greater commitment to the intervention by professionals who understood its mechanisms and content as facilitating the implementation . AdditioExercising preventive practices in the daily routine of a service and promoting a prevention culture go hand in hand . The morWhile, on the one hand, the political context turned out to be key to the success of the preimplementation and implementation, on the other, the geographic, sociocultural, socioeconomic, and aspects of the implementation process were shown to have little influence on the SFP 10–14 implementation path. A precarious infrastructure and limited financial resources were relatively low-impact challenges for the implementation, even though program delivery occurred in one of the poorest regions of Brazil. Similar findings were uncovered in a systematic review that synthesized recommendations derived from 31 evidence-based program evaluations for solving problems related to public health policies . Ubbink The political context brought the greatest number of implementation barriers, the most cited being the management decision-making concerning the administration of people and financial resources and the existence of coalitions between networks, even before the program’s entrance into the local context. The first issue is coherent with international literature , accordiIntersectorality also played a prominent role as a barrier, though less so than the its facilitative role. Interviewees discourse evinced difficulties with operationalizing intersectoral actions even before the arrival of SFP 10–14, which suggest the need to improve coordination between assistance, health care, and education before the municipality adopts the program. When appropriate, intersectorality reduced common barriers to program planning, allowing for better distribution of tasks and, consequently, a reduced overload for the professionals.Likewise, the working conditions of the professionals, particularly in team training and SFP 10–14 delivery stages, was highlighted as a barrier. The workload in their existing activities (outside of SFP 10–14) left little time for planning. Similarly, Patterson  pointed Practical implications can be extracted from the present study. First, to improve the implementation quality of SFP 10–14 in Brazil, public administration would need to be committed to the costs demanded by the programming planning and execution, including those related to the group facilitators’ working conditions, which was considered one of the main challenges to engagement and to logistical organization in the program’s execution. Second, improvements in the intersectoral coordination are needed in order to reduce obstacles to program planning, enhance task distribution, and lower the professionals’ workload. Third, implementation strategies could be strengthened by teaching skills for managing groups, the intervention’s change mechanisms, and strategies for reaching the target audience to implementation agents. Finally, monitoring and supervision should be maintained, as the reports indicate that doing so reduced errors arising from the team training stage and impacted group facilitator self-efficacy and delivery quality of the program .The present study, to our knowledge, pioneered the systematic examination contextual elements influential to the implementation of SFP 10–14 as a public policy tool. It was innovatively based on the CICI model, that has the advantage of providing a detailed and broad description of context phenomenon and its relationship with implementation of complex interventions. This model has shown to be compatible with the research question of this study, by allowing the understanding of how much the context has an influence on the successful outcomes of a policy or program, such as the SFP 10–14. Furthermore, it enabled an objective categorization of the observed events. In addition to this, the study’s results expand the findings Latin American studies already available, where there is a paucity of research on the intervention’s implementation and effectiveness . AccordiLimitations can be seen in this study. It is assumed that the results found would be on firmer ground if triangulated from the perspective of the group facilitators, professionals who work with SFP 10–14 more actively starting from the team training stage. Furthermore, this research did not use methods of data collection other than interviews and focus groups. Therefore, the typical social desirability of verbal measures constitutes an important bias that should be considered when interpreting these findings. Finally, the data was collected at a specific point in time, in a cross-sectional analysis, which may mask historical subtleties that could be revealed in a longitudinal or ethnographic design with longer and deeper field immersion.This study’s findings suggest the SFP 10–14 implementation was perceived as onerous and complex, with barriers being reported with slightly higher frequency than facilitators, and whose viability requires a favorable political context, engaged implementation agents, and carefully-designed implementation strategies. Investment in the various preimplementation and implementation phases should be made in management, key actor awareness, and implementation strategy quality. The results highlight the importance of examining organizational and community readiness to verify the conditions necessary for SFP 10–14 preimplementation and implementation in the public sector, or risk it being impractical .Future studies could analyze to what degree favorable or unfavorable SFP 10–14 implementation contexts impacted its effectiveness and sustainability in states where it was implemented as an integral part of the National Drug Policy. Therefore, study designs capable of covering the interrelationships between the result patterns, mechanisms, and contexts would represent an important contribution to the area by uncovering the circumstances that explain the effectiveness of SFP 10–14 or its absence . Similar


The working‐age population is rapidly declining in Japan, so the government has adopted “health and productivity management” (HPM). This policy initiative aims to encourage corporations to view health promotion activities as an investment in their employees’ health. The objective of this study was to examine the association between organizational factors and knowledge of the organization's effectiveness and program participation levels, and to understand the factors that affect effectiveness of corporations’ activities.We used data from all corporations that completed the HPM Survey Sheets in 2018 (n = 1800). The explanatory variables were organizational factors: written company‐wide policy, agenda item at management‐level meetings, regular education for managers, and full‐time occupational health staff. The outcome variables were knowledge of the corporation's status on the effectiveness indicators  and rates of participation in four areas . The associations between organizational factors and knowledge on effectiveness indicators and rates of program participation were analyzed using multiple logistic regression analysis.All the organizational factors were related to knowledge of effectiveness indicators, but only some were associated with the program participation indicators in the model, including all explanatory variables.Enhancing organizational factors may lead to improvement of HPM programs and higher program participation among employees in corporations. These are submitted by applicant coporations.Many studies have been conducted on organizational factors influencing the effectiveness of health promotion programs. The importance of factors related to leadership and commitment has been highlighted.The METI discloses individual questionnaires from applications to encourage the generation of evidence on HPM. Drawing on the findings of previous studies, the factors that may influence the results of health promotion activities in the workplace can mainly be categorized into two of the four areas measured by the HPM Survey Sheets Table . By analIn this study, we examined the relationships of key items in the areas of “the positioning of HPM in the corporation's philosophy and policies” and “organized frameworks” in the HPM Survey Sheets with each corporation's knowledge about its status on indicators of effectiveness and program participation. These two areas of the HPM Survey Sheets correspond to the organizational factors influencing the effectiveness of health promotion programs.22.1This was a cross‐sectional study.2.2In the HPM recognition programs, participating corporations voluntarily downloaded the HPM Survey Sheets from the METI’s website, filled in the answers, and submitted them.We obtained the results from each corporation's response to the 2018 HPM Survey Sheets. The data from all corporations that completed the sheets were used. The details of the composition of the questionnaire have been previously published.2.32.3.1We selected four explanatory variables for analysis. In the area of “the positioning of HPM in the corporation's philosophy and policies”, we used whether there was a “written company‐wide policy for the promotion of HPM” (written company‐wide policy) to measure the organization's commitment. The existence of an “agenda item on the promotion of HPM at management‐level meetings” (agenda item at management‐level meetings) was used to operationalize the integration of HPM initiatives into the organization's business practices. In the “organized frameworks” area, the presence or absence of a “full‐time occupational physician and occupational health nurse”  was used to assess the assignment of dedicated departments and staff. The presence or absence of “regular education for managers on health maintenance and promotion measures” (regular education for managers) was used to measure support for middle management as leaders.2.3.2The outcome variables were classified into indicators of knowledge about the corporation's HPM status and indicators of program participation.In the HPM Survey Sheets, the presence or absence of aggregation of the numerical indicators is first confirmed, and if aggregated, the numerical values are entered. We selected four indicators of knowledge about the status of the corporations, considering the steps and difficulties in identifying each numerical indicator. The first indicator was the percentage of employees engaging in exercise (exercise habits), which is defined in the HPM Survey Sheets as engaging in 30 minutes or more of exercise inducing light sweating on 2 or more days per week. In Japan, corporations have tended to use the standardized questionnairesIn the HPM Survey Sheets, there are five indicators of program participation: the percentage of employees participating in education on health maintenance and promotion , support programs to establish exercise habits (exercise program), and support programs to improve dietary habits (dietary program); the percentage of employees receiving the influenza vaccine (influenza vaccination), and efforts to promote communication. Four of these items were targeted, excluding efforts to promote communication, which tend to be wide ranging and are difficult to interpret. With regard to the content of programs to establish exercise habits and programs to improve dietary habits, the Survey Sheets ask the respondents to answer the programs they provide, to select the most important program among them, and then answer the participation rate for each. To avoid duplicate evaluation of the same program, programs to provide information about a healthy lifestyle, such as group education, are instructed to be excluded from the programs. The indicators of program participation have the following response options: <20%, 20%‐50%, 50%‐80%, ≥80%, and “no information”. The median for all the participation indicators was either in the range of 50% to 80% or ≥80%. We therefore defined a high participation rate as ≥80%. If they answered “no information”, they were regarded as <80%, and therefore not a high participation rate.2.3.3The activities underlying HPM and health promotion were expected to be influenced by the industry sector and the corporation size. We therefore used information from the questionnaire about industrial classification and number of full‐time employees as adjustment variables. The number of full‐time employees was used as a continuous variable.2.4We used multiple logistic regression analysis to examine the relationships between each of the outcome variables and the explanatory variables. In Model 1, we adjusted only for industrial classification and number of full‐time employees and analyzed the relationship between each explanatory and outcome variable separately. In Model 2, in addition to the adjusted variables in the Model 1, we simultaneously adjusted for all explanatory variables.For the indicators of knowledge about the corporation's HPM status among the outcome variables, missing values were defined as those for which the presence or absence of aggregation was not mentioned. In the case of indicators of program participation, missing values were defined as those where none of the options including “no information” were selected. Samples with missing values were excluded in the analyses. In addition, we conducted a sensitive analysis by treating the missing value as “No” for Model 2.We used Stata release 16  for all analyses.2.5The METI obtained consent from all responding companies to use these data for research purposes. We also signed a written commitment with the METI to ensure that the data would be kept within the institution and to confirm that we would not disclose the results in a form that made it possible to identify any individual corporation. Additionally, we did not handle individuals’ personal information.3In total, 1800 corporations  submitted the HPM Survey Sheets. At the end of 2019, 3706 corporations were listed in the Japan Exchange Group; 23.1% of these listed corporations submitted the questionnaire  and visiting hospital . Some relationships remained for knowledge of employees at risk of high blood pressure  and long‐term sickness absence . However, there were no longer significant relationships between knowledge of employees’ status with full‐time occupational health staff and between knowledge of long‐term sickness absences and written company‐wide policy.3.2Table In Model 2, the associations of health education with agenda item at management‐level meeting , dietary program with regular education for managers , and influenza vaccination with agenda item at management‐level meeting  remained significant.3.3When the missing value was analyzed as “No”, the combinations of an explanatory variable and an outcome variable showing a significant difference were added in Model 2. For the effective indicators, there were relationships between written company‐wide policy and long‐term sickness absences. For the program participation indicators, there were relationships between written company‐wide policy and health education, exercise program, and dietary program; between agenda item at management‐level meetings and dietary program, and between regular education for managers and exercise programs.4In this study, using corporations’ responses to the HPM Survey Sheets, we investigated the associations between knowledge of the corporation's status on HPM‐relevant indicators and indicators of program participation with four organizational factors: written company‐wide policy, agenda item at management‐level meetings, full‐time occupational health staff, and regular education for managers. It was considered that these organizational factors corresponded to the organization's commitment, the integration of HPM initiatives into the organization's business practices, the assignment of dedicated departments and staff, and supporting middle management to lead.We confirmed that each organizational factor was related to knowledge of the corporation's status on the selected indicators. The process of gathering information on indicators related to employees’ health status is essential to understand the needs for programs and the opportunities for improving HPM initiatives. Corporations must be motivated to improve their HPM initiatives to generate effective results, and this motivation is unlikely without management commitment and managerial leadership.The item gauging knowledge of the corporation's long‐term sickness absences was less likely to make a difference than the other outcome variables. This information is usually compiled by human resources departments based on employees’ medical certificates, regardless of whether the corporation promotes HPM. However, it is worth noting that having a written company‐wide policy for the promotion of HPM and HPM as an agenda item at management‐level meetings were associated with knowledge of long‐term sickness absences. To the best of our knowledge, no previous reports have examined the relationships between organizational factors and knowledge about the corporation's status on HPM‐relevant indicators.We observed that organizational factors were selectively associated with indicators of program participation. Having a written company‐wide policy or full‐time occupational health staff was not associated with any of the program participation indicators. However, HPM as an agenda item at management‐level meetings was associated with health education and influenza vaccination, and regular education of managers was associated with health education and dietary program participation, when all factors were included in one model. Lier et al noted that user rates of health promotion platforms offered in Germany varied greatly (from 0.07% to 100.00%) among client corporations and that organizational support for management to encourage participation in the program increased the program participation rate.In this study, we found relationships between program participation and organizational factors, which generally supports previous findings. However, previous studies did not consider how each program is associated with different organizational factors. Even if a policy is documented and disseminated, it may not encourage employee participation without an accompanying organizational commitment. The same is true of having full‐time occupational health staff. Integration of HPM initiatives into the organization's business practices is often recognized in best practice models,A strength of this study is that it used real‐world empirical data from a survey of corporations. This type of study is useful for clarifying the relationships between factors in actual situations. Previous work using surveys and checklists that are used in practice for nonresearch purposes includes studies using data from the Britain's Healthiest Company contestThis study had several limitations. First, the HPM Survey Sheets used to provide the study data are self‐administered. The accuracy of the information is therefore uncertain. For example, it is not clear precisely how the respondents aggregated the true data to produce the summary measures requested. Additionally, the purpose of submitting the Survey Sheets is for corporations to be certified in the HPM Stock Selection and the Certified HPM Corporation Recognition Program. There is therefore an incentive to present the organization in a positive light. If there are any major false statements, the certification will be revoked. However, the METI is currently conducting a field survey to introduce actual activities of certified corporations in the HPM Stock Selection as good examples,Despite these limitations, our study suggests that the enhancement of organizational factors, in addition to the provision of health promotion programs, is important for good outcomes from HPM. These findings provide meaningful insights for the future promotion of HPM in corporations and for the effective operation of HPM initiatives by the government.5Using real‐world data, we found that organizational factors affect knowledge of status on indicators of effectiveness and participation rates in health promotion programs in Japan. The impact of each organizational factor varied by indicator and programs. The findings suggest that the enhancement of organizational factors may increase the effectiveness of workplace health promotion initiatives through continuous improvement of programs and high program participation among employees.Approval of the research protocol: N/A. Informed consent: The METI obtained consent from all responding companies to use these data for research purposes. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: The authors have no conflicts of interest directly relevant to the content of this article.HT, MN, TN, and KM conceived the study; HT analyzed the data with support from TN and KM. HT and KM led the writing. All authors participated in critically reviewing the study.


P = 0.024) and Fars . The DENV and CHIKV seropositivity rate in summer is higher than in other seasons (P < 0.01). Our seropositive samples suggest possible CHIKV and DENV infection in Iran. It is likely that these viruses are circulating in Iran and there is a need to study vector carriage of these two viruses.After the mass campaign of Measles and Rubella vaccination in 2003 in Iran, the cases of measles and rubella infection decreased but still, the cases of rash and fever were reported. It is worth noting that some other viral infections show signs similar to measles and rubella such as some arboviruses. Considering the epidemic outbreak of arbovirus infections in countries neighbouring Iran, we performed this study to estimate the possibility of chikungunya and dengue fever among measles and rubella IgM negative patients presenting with rash and fever from December 2016 to November 2017 in the National Measles Laboratory at Tehran University of Medical Sciences. Serum samples were selected at random from patients from eight provinces. The presence of DENV IgM and CHIKV IgM was examined by enzyme-linked immunosorbent assay. Of the 1306 sera tested, 210 were CHIKV seropositive and 82 were dengue seropositive. Statistical analysis demonstrated a significant increase in the CHIKV IgM antibody seropositivity rate in Kerman (OR = 2.07, 95% CI: 1.10–3.92;  Aedes species including Aedes aegypti and Aedes albopictus mosquitoes which are distributed throughout the world [Measles and rubella infections in Iran decreased due to the mass campaign of measles and rubella vaccination in 2003  but stilhe world , 12. Sighe world . In Iranhe world , 14.Ae. albopictus and Ae. aegypti was carried out in spring, summer and winter, 2008–2014 in eight provinces [Ae. albopictus larvae were collected in the Sistan & Baluchestan province bordering Pakistan in 2009 [Ae. albopictus adult mosquitoes were also detected in a coastal location neighbouring Chabahar in the same province [Ae. albopictus is regarded as a conspicuously menacing and versatile species that inhabits both temperate and tropical climate regions [Ae. albopictus establishment [Therefore, Iran is strategically placed at a remarkable risk zone for these arboviral diseases. In addition, the introduction of exotic vectors into Iran is possible . Active rovinces  followinrovinces . Ae. alb in 2009 . In 2013province . Ae. alb regions , 18. Sin regions  and on p regions . In addilishment . Hence, NML in the School of Public Health, Tehran University of Medical Sciences, every year, receives about 6000 samples from suspected cases of measles and rubella, and laboratory diagnosis was made using IgM capture enzyme-linked immunosorbent assay (ELISA) for measuring IgM anti-measles and IgM anti-rubella antibody.Ae. albopictus and Ae. aegypti was carried out in spring, summer and winter, 2008–2014 in those regions.Serum samples were collected randomly from eight provinces  from Dec2 located in the Middle East with a diverse climate [Iran is a country with an area of 1,648,000 km climate . Among t climate . Khuzest climate .The presence of DENV IgM and CHIKV IgM were examined by a commercial Semiquantitative IgM ELISA kit according to the manufacturer's instructions (EUROIMMUN Anti-CHIKV/IgM) and .P-Value <0.05 was considered significant.Statistical analyses were performed using the SPSS software, version 16. Fisher's exact test was performed for the evaluation of qualitative variables including sex, province and season. In order to explain the relationship between dengue and chikungunya infection and independent variables, logistic regression was performed. In this study, serum samples from 1306 patients from eight provinces were tested.The overall CHIKV and DENV IgM seropositivity was 16.07% (210/1306) and 6.27% (82/1306) respectively. A summary of the characteristics of the study of all the patients was presented .P = 0.024) and Fars .The rate of chikungunya seropositivity among patients from the eight provinces ranged from 9.18% in Khuzestan (28/305) to 23% in Ilam (23/100) . The rats.d.) age of the studied cases was 6.05 (±9.536). The highest anti-CHIKV seropositivity rate was observed in infants (17.6%). Also, most of the dengue positive cases belonged to infants (7.9%). Although the CHIKV seropositivity rate was higher in infants, CHIKV seropositivity was not statistically significant based on the age group (P = 0.3). Besides, the observed difference between anti-dengue and age in this study was not significant (P = 0.09).The patients were divided into four age groups comprising less than or equal to 1 year (infants), 2–18 years (youths), 19–64 years (adults) and more than 64 years (elderly). The frequency distribution of the various age groups encompassing groups 1 to 4 stated above was 48.2% (629/1306) for infants, 43.3% (566/1306) for youths, 8.2% (107/1306) for adults and 0.3% (4/1306) for elderly respectively. The mean  in the male group and 101/605 (16.69%) in the female group were positive for anti-IgM CHIKV antibodies and 33/701 (4.07%) in the male group and 49/605 (8.09%) in the female group were positive for anti-IgM DENV antibodies.P = 0.015).The highest dengue seropositivity rate was seen in the female group in youths , and the infection rate in summer was higher than in other seasons .In terms of season, there was a statistically significant difference in the anti-DENV and anti-CHIKV IgM antibody seropositivity rate between the patients grouped based on the season  in our study. On the other hand, vector mosquitoes are mainly active in the summer season [Since 2005, and Iran . Althougand Iran . Despitemutation . Ae. alblsewhere . For exa in Iran . A numbe in Iran , heavy r in Iran , war and in Iran , migrati in Iran  and heav in Iran , that ma in Iran . With thr season . Based oAlthough our study shows no significant difference in the different age groups, however, the prevalence suggests that dengue fever often occurs in children, despite the fact that the older age group has been witnessing an increase in dengue fever infection in recent years .Even though in our study, the presence of the CHIKV IgM antibody is not associated with gender, on the other hand, the anti-dengue IgM antibody is higher in females than in males, which it is not in line with previous reports that exhibited an excess of male patients in Iran , MalaysiAe. aegypti and/or Ae. albopictus, in a population with low herd or community immunity [Flaviviruses, with other viral infections such as West Nile Virus, which had been previously reported in Iran was not taken into consideration [Given that chikungunya and dengue fever epidemic is engendered by either immunity , it is nderation . AnotherThe results from this study suggest that there has been an exposure to DENGV and CHIKV by a local population in Iran. This is an important issue for future research studies and further population-based work is required in order to investigate and assess the degree of exposure of the population to the presence of dengue and CHIKV in Iran.


In 2020, the Center of Innovation for Veteran Centered and Value Driven Care (COIN) continued its monitoring and evaluation of the Veterans Administration (VA) Medical Foster Home (MFH) programs expansion into rural areas. Veterans in MFHs are provided 24/7 care by VA trained and supervised community caregivers and primary care by VA Home Based Primary Care (HBPC) teams. One year after the three-year (2017-2019) expansion funds stopped, COIN continued monitoring remaining programs. Objectives were to understand factors critical for program expansion and sustainability and the impact of COVID-19. Phone interviews were conducted with sixteen coordinators from seventeen programs. A thematic analysis approach was used to address the evaluation objectives using transcript data. Findings showed factors important to program sustainability were: 1) Program fit (finding caregivers in the community); and 2) Local VA facility support . COVID prompted losing some caregivers and prevented others from joining. Program staffing was not impacted as many program activities ceased. Recreational therapists (RTs) were significant to maintaining Veterans well-being and reducing social isolation through virtual activities. COVID required coordinators transition their supervision of MFHs to new virtual environments and HBPC to increase telehealth to new levels. Local leadership became important to monitoring local conditions and providing support to programs. The evaluation: 1) Found factors important to program sustainability were also critical to keeping programs operational during the pandemic; and 2) Stimulated future research on the suitability of MFH programs to meet challenges to resurgences of COVID or other national emergencies.


The Right Care, Right Place, Right Time initiative (R3) was developed to enable seniors to remain at home as long as possible, while reducing health care costs. It was implemented in four senior housing communities in the Greater Boston area, and consists of two on-site wellness teams , each responsible for about 200 participants across two housing sites. This study aimed to understand barriers and facilitators to implementing R3. Data derived from 31 semi-structured interviews with R3 staff, housing personnel, and community partners , as well as 150 key program documents. Facilitating factors in implementing R3 included: top-level management support; formal and informal mechanisms of communication between wellness team members and building staff; substantial discretion, flexibility, and creativity provided to wellness team members; and daily ambulance reports from first responders. Barriers to implementing R3 included: impediments to resident recruitment/engagement; initial role confusion between wellness team members and existing building staff; limited wellness team time at individual intervention sites; challenges establishing systematic relationships with case management staff from the hospitals, AAAs, and insurance companies; and the decentralized approach to data tracking and information exchange. This study suggests several lessons for implementing housing with services initiatives such as R3. Top-level support and buy-in at the organizational level is essential to program development and implementation. Despite early challenges, key program elements can improve over time . Establishing trust with both R3 participants and housing staff is key to building relationships that promote program success.


To improve physical, mental, and social health of the rural older adults, we developed an integrated healthcare program. The program improved physical functions, loneliness, and role self-efficiency of the rural older adults. Therefore, it is recommended that healthcare professionals actively apply this program in primary healthcare institutes and elsewhere.Studies have been conducted on the development of healthcare programs for older adults in rural areas, not only in Asia but also in Europe and the United States. However, these reports have been limited by largely non-comprehensive results, lack of demand surveys, or programs with no systematic development. The purpose of this study was to develop an integrated healthcare program for rural older adults and investigate the effects of the program. A nonequivalent control group pretest–posttest design was used. Subjects were aged over 65 and lived in the rural community. The integrated healthcare program involved 12 three-hour sessions over 12 weeks. Compared with the control group, the experimental group demonstrated significant differences in both upper extremities strengths (t = 2.74,  The development of modern medical science, increased average life expectancy, and decreased birth rate have caused an international trend toward an aging society. The rapidly aging population has become a crucial social issue in Korea, with 14.3% of the population aged 65 years and above in 2018, expected to rise to 20.8% by 2026 [Older adults experience pain and dysfunction due to physical difficulties associated with aging, financial difficulties, alienation due to role loss, intergenerational conflict, loneliness, and depression . A negatAccording to the Roy Adaptation Model (RAM), which is widely applied in practical nursing, humans adapt to the changing environment using cognitive and controlling mechanisms, and nursing is a science that expands humans’ adaptive abilities and triggers changes in humans and the environment. Nursing also aims to assess adaptive systems, increasing individuals’ adaptability and ultimately improving health . VariousThe purpose of this study was to develop an integrated healthcare program based on the RAM and to verify its effects on the physical functions, loneliness, ego integration, and role self-efficacy of rural older adults.Aging can be divided into physical, psychological, and socio-relational aging. In old age, physical aging is most frequently observed and the risk of cognitive disorders such as memory and intelligence decline and dementia increases . FragiliIn particular, older adults living in rural areas were found to have living conditions and welfare needs that are different from those of the older adults living in urban areas. In the case of Korea, the gap between regions in terms of living environment and population characteristics between urban and rural areas has widened along with economic development. Compared to cities with better access to welfare services, rural areas have a negative impact on the health status and quality of life of rural older adults due to the aging population, labor shortage, and lack of preventive healthcare services and facilities . These sThe World Health Organization defines health as a state of physical, psychological, and social well-being. Therefore, for healthcare of older adults, programs aimed at improving psychological and social health and physical aspects should be planned. Deterioration in physical function due to aging leads to decreased immunity, increased vulnerability to disease, and reduced recovery, and thus training to improve physical health is needed ,18,19. HTherefore, healthcare programs for older adults mostly include physical activities as a major component. Since the National Blueprint in 2001, the USA has been striving to promote physical activity for older adults in many ways. In particular, experts are beginning to pay attention to the verification of the effectiveness of physical activity programs, and these verified programs are being disseminated systematically. Major healthcare programs in the USA that are provided to senior citizens include Active Choices, Strong for Life, Healthy Moves for Aging Well, Tai Chi, and Fit and Strong, among others, which are reported to be effective in preventing falls and improving independence and reducing depression among older people . On the Although prior studies on health management programs for rural older adults focused on disease, loneliness, and poverty , they diIn order to lead a healthy life in old age, one must adapt well to the changes and problems in various aspects that emerge in old age. Integrated programs are needed to maintain physical and social health through active social participation and mental health that can reduce anxiety and fear of isolation or death, alienation, and helplessness ,12,13. TA nonequivalent control group pretest–posttest study design was used.A convenience sample was recruited from J province in South Korea. The inclusion criteria were (1) being a rural community-residing older adult aged 65 and over, (2) being able to communicate, and (3) the ability to understand the study purpose and provide written consent to voluntarily participate. The following were excluded from this study: (1) individuals who have participated in any health-related program within one year, (2) being unable to participate in physical activities due to movement difficulties, and (3) being diagnosed with serious diseases such as Alzheimer’s or cancer. n = 41) was recruited from two halls for the older adults in J province, while the control group sample (n = 41) was convenience sampled from J province and had similar general characteristics and living environments but no social intercourse with the experimental group, giving a total of 82 subjects. During the study, two subjects from the experimental group  and three from the control group  dropped out, resulting in a final analysis of 77 subjects  , age , religion , education level , residence type , and perceived economic status  between the control and experimental groups  . The avel groups . This study was certified by the ethics review board (IRB no. 2017-06-015-002). All subjects provided written informed consent to voluntarily participate and were given small gifts. After the study, the control group subjects were given workbooks from the integrated healthcare program.The program was developed on the basis of a needs analysis of the subjects and existing literature to investigate effective contents for integrated healthcare for the older adults. The program was developed in the order of goal-setting, program construction, and publishing workbooks. To construct the program contents, we examined previous literature from the past 10 years with the key words “rural older adults health”, “rural older adults programs”, “integrated healthcare program”, and “integrated health promotion program”. As a result of reviewing data from papers we searched for that were written over the past 10 years, the most frequently reported effects were found through providing exercise-related programs for physical health management.A semi-structured needs analysis survey was then conducted with 20 rural older adults who visited a center for the older adults in J province and who could understand the survey purpose and who provided written consent to voluntarily participate. Six respondents (30.0%) had participated in health-related programs. When asked about difficulties in their daily lives, health-related difficulties were the most common, followed by loneliness, economic problems, and communication in personal relationships. The most sought-after program was “how to prevent Alzheimer’s disease”, followed by “how to be healthy”, “home exercise”, “singing”, “dancing”, and “drawing”. According to the needs analysis, the program included contents on physical activities, recreation, strengthening cognitive abilities, and communication for good personal relationships, among others. Increasing physical functions, ego integration, role self-efficacy, and decreasing loneliness were selected as the program goals to increase the physical, mental, and social health of the older adults. Finally, the RAM was selected as the theoretical basis of the program to describe the successful adaptation outcome of the rural older adults. On the basis of prior studies, the program was divided into 12 sessions. To verify the program’s content validity, we selected an expert group of four people—three nursing professors and one program staff member of the health center—who assessed the validity of each program topic on a four-point Likert scale. The Content Validity Index (CVI) of all topics exceeded 0.75, determining content validity. The developed program was named the “Integrated Healthcare Program for the Older Adults”.Each session was designed to comprehensively connect the four adaptive modes from the RAM to increase physical functions, ego integration, and role self-efficacy and decrease loneliness. First, to improve the physical function of the subjects, which was considered the physiological mode, we included lectures on topics such as “successful aging”, “hypertension and diabetes self-management”, “first aid in daily life”, “safety management in older adults”, “nutrition and health”, and “oral care in old age” in the program contents. It also included cognitive strengthening exercise and small-group activities at each session to improve physical functions. Second, to enhance the ego integration, which is regarded as the self-concept mode, we included lectures on “what is logical function?” and activities such as “recall past and candle ceremony”, “create a proposal card/praise others”, and “speaking about feelings regarding the program”. Third, to increase role self-efficacy, which was considered as the role function mode, we included small-group activities such as team building, cognitive puzzle (group), cognitive board games (group), and cooking practices. Finally, to decrease loneliness, which was regarded as the interdependence mode, we delivered lectures on “communication skills in neighbors” and small-group activities such as team building, expressing through colors (group), cognitive puzzle (group), laughing, singing, and dancing, among others. The specific programs are shown in Before the study intervention, the authors and experts  were consulted regarding the study and program purpose. One-hour training was also provided to two study assistants on the study purpose and how to measure the physical functions. Afterwards, the evaluators’ consistency was calculated with four standard subjects using the Intraclass Correlation Coefficient (ICC), wherein an inter-evaluator consistency of 0.90 was achieved.Data collection was conducted at a hall for the older adults in J province for the experimental group and control group. Surveys were conducted as a single blind study, either by allowing the subjects to complete the survey by themselves or by conducting face-to-face interviews. The physical functions were measured by two assistants.The intervention was conducted from September to December 2017 in the seminar room of a hall for the older adults in J province. To ensure all subjects had identical programs, all participants attended the program simultaneously as a single group. Each session was managed by the first author and seven experts according to the program contents. The authors phoned or texted subjects the day before to remind them about the program. To encourage participation, there was an attendance board on the wall where subjects could place stickers and subjects with excellent attendance were rewarded. The average program attendance rate after 12 weeks was 99.6%.The posttest was conducted directly after the program by two assistants in the same manner as the pretest.Data collection was conducted from September to December 2017. Approximately 70 to 80 min was taken to conduct surveys and measure physical functions. Identical pretests were conducted on the control and experimental groups, and the posttest was conducted after 12 weeks of the program.Physical functions were measured according to Rikli and Jones’  Senior FLoneliness was measured using the University of California, Los Angeles (UCLA) Loneliness Scale, developed by Russell  and valiEgo integration was measured using Hong’s  Ego InteRole self-efficacy was measured using the 13 questions on role self-efficacy from Kim and Shin’s  Successft-test and Mann–Whitney U test were used for the continuous variables, and Fisher’s exact test was used to analyze cases when the minimum expected frequency was below 5 for over 20% of the total cells during the χ2 test for the categorical variables of the homogeneity test of general characteristics and prior dependent variables. The Shapiro–Wilk test was used to examine the normality of dependent variables. Nonparametric test was used for static balance since there was no normal distribution. The data were analyzed by using an independent t-test and Mann–Whitney U test to identify the differences between the experimental group and the control group at the end of the program.The data were analyzed using SPSS version 26.0  at a significance level of 0.05. Independent p = 0.051), right upper extremity strength , static balance , dynamic balance , loneliness , ego integration , and role self-efficacy   .p = 0.008) in the left upper extremity strength of the two groups, with the experimental group increasing from 16.92 ± 4.52 kg before the program to 19.08 ± 4.31 kg after, while the control group decreased from 19.87 ± 7.95 kg before the program to 18.24 ± 4.72 kg after. There was a meaningful difference  in the right upper extremity strength of the two groups, with the experimental group increasing from 18.08 ± 4.47 kg before the program to 19.37 ± 3.99 kg after, while the control group decreased from 20.13 ± 6.79 kg before the program to 19.20 ± 5.27 kg after. There was a statistically meaningful difference  in the static balance of the two groups, with the experimental group increasing from 35.88 before the program to 42.20 after, while the control group decreased from 41.78 before the program to 35.04 after. There was a meaningful difference  in the dynamic balance of the two groups, with the experimental group decreasing from 8.35 ± 1.64 s before the program to 5.95 ± 1.15 s after, while the control group increased from 8.65 ± 2.17 s before the program to 9.64 ± 3.27 s after  in the loneliness of the two groups, with the experimental group decreasing from 30.46 ± 3.27 before the program to 28.69 ± 3.13 after, while the control group increased from 29.24 ± 2.57 before the program to 29.79 ± 2.80 after  in the role self-efficacy of the two groups, with the experimental group increasing from 12.49 ± 2.67 before the program to 15.23 ± 2.18 after, while the control group increased from 13.24 ± 3.11 before the program to 14.03 ± 2.67 after  in the ego integration of the two groups, with the experimental group increasing from 52.18 ± 6.12 before the program to 55.33 ± 8.12 after, while the control group increased from 50.37 ± 4.28 before the program to 51.05 ± 4.28 after , right upper extremity strength , static balance , and dynamic balance —compared to the control group. Moreover, loneliness  and role self-efficacy  improved statistically significantly compared to the control group. The results of this study supported the previous studies [The study subjects were senior citizens aged 65 or older, with 39 experimental groups participating in the program for 12 weeks, at 120 min per week; 38 control groups did not receive the integrated healthcare program. Measurement tools for verifying the effectiveness of the program were Senior Fitness Test, UCLA Loneliness Scale, Eco Integration Scale, and Successful Aging Scale. The data analysis was performed using SPSS version 26.0 , and differences in dependent variables between the two groups were identified using the independent  studies ,36,38,39In conclusion, this study demonstrated that the integrated healthcare program we developed is effective in increasing some physical functions and role self-efficacy and decreasing loneliness. The program’s success was due to the fact that the core strategy involves providing various activities that cater to rural older adults to increase participation and interest. This study is meaningful in confirming the role of a healthcare program that integrates physical, mental, and social health factors. Furthermore, to prepare for an aging society, programs facilitating a healthy and satisfactory life after retirement by successfully adapting to the physical, psychological, and social changes that accompany aging should be provided as ongoing rather than one-time programs. Therefore, it is recommended that healthcare professionals actively apply this program in primary healthcare institutes and elsewhere, with public nurses serving either as the main program operators or cooperating with other healthcare personnel.


The aim of this study was to determine the effectiveness of the Smart Life Stay (SLS) program, which is an experience-oriented stayover program, in combination with health tourism and mandatory health guidance on glucose metabolism after 2 years.n = 792) were recruited from a database of 23 medical insurers. They underwent a mandatory health examination termed Specific Health Checkups in 2014. The participants were included if they had diabetes or were at a high risk of diabetes and if they satisfied the following inclusion criteria: (1) body mass index  > 25, or (2) waist circumference  > 85 for men and > 90 for women, or (3) hemoglobin A1c  > 5.6, or (4) fasting plasma glucose  > 100. Individuals who corresponded to one or more items were included as study participants. The control subjects (n = 3645) were nonparticipants of the program who were selected from the database and met the inclusion criteria. The lifestyle changes and changes in mean BMI, WC, FPG, and HbA1c in both groups from baseline to 2-year follow-up were compared by inverse probability weighting of a propensity score.The participants of the SLS program (2, and 1.45 cm, respectively, whereas in the control group, WC, FPG, and HbA1c increased significantly by 0.38 cm, 3.37 mg/dl, and 0.12%, respectively. The comparison between groups revealed that the BW, BMI, WC, FPG, and HbA1c improved significantly in the SLS group.The percentage of people who exercised regularly increased significantly in the SLS group compared with the control group. In the SLS group, BW, BMI, and WC significantly decreased by 1.75 kg, 0.60 kg/mThe SLS program is suggested to help improve glucose metabolism. This program could be a feasible option as a lifestyle intervention program for diabetes. Due to medical costs and loss of work, diabetes and its complications result in huge economic losses, not only for patients but also for national economies2. Numerous studies have reported that lifestyle interventions, such as a combination of diet and physical activities, are effective for the prevention of diabetes and its complications5. Therefore, the establishment of more feasible diabetes management strategies is an urgent global health issue.The number of adults suffering from diabetes was estimated to be 463 million in 2019; by 2045, this number will increase to 700 million6 for insured patients aged 40–74 years. This is one of the government’s strategies to prevent diabetes. Under this system, the medical insurers maintain a nationwide unified database of medical checkups of all insured persons. In addition, based on the results of the medical checkups, individuals with metabolic syndromes receive guidance on weight reduction. Numerous studies have already shown that this guidance is effective for weight reduction and glycemic control11 and it is also cost-effective12. However, the SHG was found to be insufficient6 for some subjects. In addition, it included patients with obesity as targeted subjects but excluded nonobese patients with diabetes and preliminary diabetes. Because nonobese patients are more common in Asian populations13, more effective strategies for those with diabetes and those at high risk of diabetes with or without obesity need to be established.In Japan, since 2008, the Japanese government has required public medical insurers to conduct medical checkups and provide guidance referred to as Specific Health Checkups (SHC) and the Specific Health Guidance (SHG)14. It provides medical treatment, relaxation, balanced diet, exercise, and cosmetic services, resulting in its growing popularity worldwide. The health tourism industry, which uses rich local and national resources, such as hot springs and natural beauty, has begun to benefit local economies; however, only a few programs have examined the effects of the health tourism on improving health.The health tourism industry has been gaining a growing global interestTherefore, a new lifestyle intervention program that combines health guidance and health tourism was developed. The Smart Life Stay (SLS) program is an experience-oriented health tourism program for patients with diabetes or those at a high risk of diabetes. In this program, the patients are treated like customers who want to take part in a holiday and health improvement program.The aim of the study was to report the 2-year follow-up results of the program on participants’ glucose metabolism and other metabolic parameters.15. Propensity score analysis was employed to examine the effectiveness of the SLS program. The SLS program participants were recruited (the SLS group: n = 792) from a database of 23 medical insurers in 2014. They underwent SHC, such as those from certain communities and workplaces.The study adhered to the statement of the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND)16 and if they satisfied the following criteria: (1) body mass index  > 25, or (2) waist circumference  > 85 for men and > 90 for women, or (3) hemoglobin A1c  > 5.6, or (4) fasting plasma glucose  > 100. Individuals who corresponded to one or more items were included as study participants. The exclusion criteria included a history of myocardial infarction or cerebral infarction, systolic blood pressure (SBP) > 160 mmHg or diastolic blood pressure (DBP) > 100 mmHg, diabetes with poor glycemic control17 or critical diabetic complications, current treatment for depression and schizophrenia, history of anaphylaxis caused by food allergies18, alcoholism19, and dementia20. The control subjects (n = 3645) were nonparticipants of the program who were selected from the same database using the same inclusion criteria. The study protocol was conducted by the Comprehensive Health Science Center Aichi Health Promotion Public Interest Foundation and has been approved by the Ethics Review Committee of the center. Other study protocols were approved by the Ethics Review Committee of the Japan Association for Diabetes Education and Care. The organizations explained the study to the subjects and obtained their written consent to participate.The participants were included if they had diabetes or were at a high risk of diabetes21. The participants were briefed about their medical condition and lifestyle through the results of their medical checkups. In addition, they were instructed to set their lifestyle improvement goals at the initial counseling. The intervention was adapted to the individual participant’s medical background and lifestyle. Health-care professionals, such as physicians, public nurses, fitness trainers, and registered dietitians, performed the intervention between April 2015 and March 2016 at resort hotels, community centers, or spas that were affiliated with the recruitment medical insurers. These professionals received training on the intervention methods before the program initiation. The components of the intervention were (1) a stayover program using the local tourism industry, (2) an experience-oriented diet and exercise program, and (3) a program that includes group sessions 25 was performed. The program included not only counseling but also familiar exercise programs, such as hiking and walking in tourist resorts. The amounts of physical activity and energy expenditure during leisure activities were measured using an activity meter or the Borg scale26. The blood glucose levels were measured using a glucometer before and after exercise to help participants realize the effectiveness of exercise.Before the program, fitness trainers evaluated the participants’ physical activity levels using pedometers. They also gave lectures about adequate exercise intensity, methods for walking safely, and self-training at home. A combination of aerobic exercise and muscle resistance training based on the Exercise and Physical Activity Guide for Health PromotionThe participants were followed up by telephone, email, or one-to-one meetings for an average of six times (3–20 times). This was done to motivate the participants to focus on their goals and solve their difficulties in achieving their goals.27. Data collection in both 2014 and 2016 included these questionnaires.Based on the national standard of the SHC, body composition parameters included weight (kg), BMI, WC (cm), and SBP and DBP (mmHg), and metabolic parameters included triglycerides , high-density lipoprotein cholesterol , low-density lipoprotein cholesterol , FPG (mg/dl), HbA1c (%), aspartate aminotransferase , alanine aminotransferase , and gamma-glutamyl transferase . All parameters were measured before and after the program in 2014 and 2016). WC was measured at the umbilical level. Moreover, lifestyle questionnaires were distributed according to the national standard of SHCs , with a power of 80% and a significance level of 5% (two-tailed). A low dropout rate was estimated as the effectiveness of the program was assessed through mandatory medical checkups.Our pilot study for SHG demonstrated that there was a decrease of 3.14 ± 10.69 in FPG from baseline to 1 year in the intervention group and 1.01 ± 16.28 in the control groupThe missing values for health checkup data and questionnaire responses were complemented by multiple imputation methods using the SPSS missing values option.t-tests. The differences in the changes between the groups with generalized estimating equations were also analyzed. As for the lifestyle questionnaires, the percentages of people who had a healthy lifestyle and were graded at the action or maintenance phase were compared between 2014 and 2016 using the McNemar test. Moreover, the percentages of people who improved their lifestyle or progressed across the stages of the trans-theoretical model29 were also compared between the groups using generalized estimating equations. The average score was substituted for the percentage of people who improved their lifestyle, such that individuals with an improved lifestyle were coded as 1. All statistical analyses were conducted with a significance level of 5% (two-tailed).In an attempt to decrease the bias between both groups, inverse probability weighting of a propensity score was performed. The propensity score using binary logistic regression analysis was estimated based on sex, age, baseline examination data, and recruitment consortiums (c Statistic 0.85). Laboratory data changes from 2014 to 2016 were analyzed through paired The participants of the program (the SLS group) included 792 individuals, whereas the control group consisted of 3645 , was longer than that in other studies, thus indicating the importance of “experience-oriented” intervention programs.The effect of this program on weight reduction and glucose metabolism was nearly equal to that of other lifestyle interventions in the real-world settingThe most unique characteristic of this program was the use of the existing database. In previous intervention trials, setting the control group was difficult. However, it was comparatively easy to set the control group by using an existing database of nationwide uniform medical checkups in Japan. Currently, lifestyle intervention programs must be performed using existing facilities and databases because of their feasibility. Thus, the success of the study is significant.This study had some limitations, including the selection bias that might have resulted from the lack of randomization. Controls were set using the inverse probability weighting for the purpose of adjusting confounding factors to maintain selection bias at a minimum. Another limitation was the possibility that the participants in both the SLS group and control group received additional lifestyle interventions as people are comparatively easy to access health information and health guidance in Japan. Third, the contents of the program lacked unity and were determined individually by each recruitment medical insurer, except for the core program. Conversely, each program might have had regional characteristics, because program flexibility was permitted.This study was conducted to investigate the effectiveness of a health tourism program for individuals with diabetes and those at a high risk of diabetes. Currently, to perform lifestyle interventions in a real-world setting, an effective use of existing facilities and databases is required. This program might be a feasible option for a lifestyle intervention program for patients with diabetes and those at a high risk of diabetes. In the future, this program has the potential to improve the health of participants and to provide economic benefits to local communities.Supplemental Table 1Supplemental Table 2Supplemental Table 3Supplemental Table 4