Long-term care in the United States: policy themes and promising practices

Developing a Conceptual Framework for an Age-Friendly Health System: A Scoping Review

BACKGROUND

Population aging is usually associated with increased health care needs. Developing an age-friendly health system with special features, structure, and functions to meet the special needs of older people and improving their health status and quality of life is essential. This study aimed to develop a conceptual framework for an age-friendly health system, which would offer a conceptual basis for providing the best possible care for older people in health system to let them experience a successful, healthy, and active aging.

METHODS

A scoping review was used to design the conceptual framework based on Arksey and O'Malley's model, including six stages, with the final stage of using expert's opinions to improve and validate the initial framework. The health system model of Van Olmen, was selected as the baseline model for this framework. Then, by reviewing the available evidence, the characteristics of an age-friendly health system were extracted and incorporated in the baseline mode.

RESULTS

Using the electronic searching, initially 12 316 documents were identified, of which 140 studies were selected and included in this review study. The relevant data were extracted from the 140 studies by two reviewers independently. Most studies were conducted in 2016-2020, and mostly were from United States (33.6%). To have an age-friendly health system, interventions and changes should be performed in functions, components and objectives of health systems. This system aims to provide evidence-based care through trained workforces and involves older people and their families in health policy-makings. Its consequences include better health acre for older people, with fewer healthcare-related harms, greater care satisfaction and increased use of cost-effective health services.

CONCLUSION

To meet the needs of older people, health systems should make interventions in their functions for better performance. In line with these changes, other parts of society should work in harmony and set the health of older people as a top priority to ensure they can have a successful aging.

Care services for older persons: A scoping review

Introduction

With an increasing life expectancy and proportion of older adults, the number of people in need of care services is also increasing. This study aimed to determine and describe various available care services for older persons reported in literature.

Methods

English-language articles published between the years of 1990 and 2018 in Scopus, ProQuest, PubMed, and Google Scholar databases or search engines were reviewed. The search resulted in 46,927 articles. All selected studies were systematically evaluated and screened based on title, abstract, and full text related to the study's objective. Finally, 246 articles were included in the study. The care services in older persons care systems were identified from the selected articles and were presented in extraction tables. Final conclusions were made based on the types of services provided and their frequency of citation.

Results

The research results showed that numerous systems exist to provide care services for older adults, including long-term care services, home care services, housing for the aged, day care centres, senior centres, nursing homes, and hospice care services. Regarding older adults' care needs and the objectives and missions of each care system, different care services, such as personal care, social support services, medical care services, and nutrition services, have been identified in the service packages.

Conclusion

This study describes the diverse care services available for older persons that have been reported in the literature. Further research in different healthcare systems is required regarding what is most essential and lacking in each setting.

Survey Deficiencies as Quality Indicators in Oregon Assisted Living Communities

BACKGROUND AND OBJECTIVES

License inspection data have commonly been used as a quality measure for nursing homes but has not yet been used to assess the quality of assisted living/residential care (AL/RC) communities. Drawing on resource dependency theory, we test the hypothesis that structural and environmental characteristics influence AL/RC quality as measured by deficiency citations ("deficiencies") issued during license inspections.

RESEARCH DESIGN AND METHODS

Using data from 526 licensed AL/RC communities in Oregon that received a license inspection visit between 2008 and 2016, we examined the prevalence of deficiencies by type and year. We estimated regression models to identify structural and environmental characteristics associated with the number of deficiencies.

RESULTS

Most (79%) inspections resulted in at least one deficiency. The most common deficiencies concerned medications and treatments (57%), change of condition and monitoring (48%), and resident health services (45%). Structural characteristics associated with higher odds of receiving one or more deficiencies included: larger size, memory care designation, shorter administrative tenure, and for-profit status. Environmental characteristics associated with higher odds of receiving one or more deficiencies included: rural location, lower unemployment, and market concentration. The number and likelihood of a given community receiving a deficiency decreased over time.

DISCUSSION AND IMPLICATIONS

Resource dependency theory constitutes a useful framework to consider the role of structural and environmental factors that affect AL/RC quality, including resident needs, institutional knowledge, resource availability, and market pressure. License inspection data are a viable option for assessing the quality of AL/RC communities.

Relationship Between Working Conditions, Worker Outcomes, and Patient Care: A Theoretical Model for Frontline Health Care Workers

Despite the integral role that frontline health care workers play in providing care to older adults and those with chronic conditions and disabilities, few studies have examined the relationships between the working conditions endured by this workforce, the quality of the care they deliver, and the outcomes of patients for whom they care. Thus, the authors: (1) developed a novel conceptual framework that highlights these relationships and (2) performed a comprehensive search and analysis of the literature (PubMed, AgeLine, Cumulative Index to Nursing and Allied Health Literature (CINAHL), JSTOR, Scopus, Web of Science) to assess the relationships proposed in the framework. A total of 31 studies were included. The results suggest that working conditions affect workers themselves, the care they deliver, and their patients' outcomes. Additional studies, as well as policy solutions, are needed to address the issues faced by this workforce in order to improve health care delivery.

Infection preventionists' experiences during the first nine months of the COVID-19 pandemic: Findings from focus groups conducted with Association of Professionals in Infection Control & Epidemiology (APIC) members

INTRODUCTION

A novel human Coronavirus (SARS CoV-2) was identified in January, 2020 and developed into a pandemic by March, 2020. This rapid, enormous, and unanticipated event had major implications for healthcare. Infection preventionists (IP) have a critical role in worker and patient safety. IPs' lessons learned can guide future pandemic response.

METHODS

Seven focus groups were conducted with APIC members in September and October, 2020 via Zoom to elicit IPs' experiences during the COVID-19 pandemic. Sessions were recorded then transcribed verbatim. Major themes were identified through content analysis.

RESULTS

In total, 73 IPs participated (average of 10 IPs per focus group) and represented all geographical areas and work settings. Participating IPs described multiple challenges they have faced during the COVID-19 pandemic, including rapidly changing and conflicting guidance, a lack of infection prevention recommendations for nonacute care settings, insufficient personal protective equipment, healthcare personnel complacency with personal protective equipment and infection prevention protocols, and increases in healthcare associated infections and workload.

CONCLUSIONS

The identified gaps in pandemic response need to be addressed in order to minimize healthcare associated infections and occupational illness. In addition, the educational topics identified by the participating IPs should be developed into new educational programs and resources.

Does Gender Matter in the Receipt of Informal Care Among Community-Dwelling Older Adults? Evidence from a Cross-National Comparative Study Across the United States, South Korea, and China

OBJECTIVES

This study compares patterns of gender difference in the receipt of informal care among community-dwelling older adults across the United States, Korea, and China where family-oriented systems for providing care to older adults are emphasized.

METHOD

Data came from the 2014 Health and Retirement Study, the 2014 Korea Longitudinal Study of Aging, and the 2015 China Health and Retirement Longitudinal Study. Logistic regression models were used to predict the receipt of informal care by gender. We also examined how the effects of health and living arrangement on the receipt of informal care differ depending on gender.

RESULTS

In the United States and China, older women were more likely to receive informal care than men. However, older Korean women were less likely to receive informal care than men. The effects of health and living arrangement on the use of informal care were moderated by gender in different ways across countries.

DISCUSSION

This study provides evidence that patterns of gender differences in the receipt of informal care vary across the three countries. More attention needs to be paid to the design and implementation of long-term supports and services to address the unique patterns of gender difference in care arrangement in each country.

Social Support and Stressors among VA Medical Foster Home Caregivers

This study aimed to identify sources of social support and stressors that facilitated or hindered caregivers in the Department of Veterans Affairs (VA) Medical Foster Home (MFH) program in performing their duties. We conducted phone interviews with 35 caregivers and found they relied on work-related, religious, and emotional social support. Caregivers' unmet needs included a lack of time to re-charge; affordable respite services; enough VA-paid relief services, adequate relief caregivers; and ability to attend church. To address these needs, VA leadership should make MFH caregivers eligible for VA Caregiver Support Programs, encourage reciprocal caregiving arrangements, and organize virtual church services.

Nursing home social services: A systematic review of the literature from 2010 to 2020

Nursing home (NH) social workers carry out person-centered care, guided by the 1987 Nursing Home Reform Act. As the projected population of individuals requiring NH care is expected to grow and become more racially and ethnically diverse, the social worker in this setting becomes increasingly important. The aims of this study are to: (1) identify existing research that discusses the role of social work and nursing facilities, (2) synthesize findings to determine what is most often reported in the literature, and (3) present recommendations for practice, research, and policy. This study used the PICO framework and PRISMA guidelines to systematically search for articles published in English between 2010 and 2020 across 11 databases. A final sample of 23 articles discussed social work in the NH organized into three categories: (1) qualifications of the NH social worker (n = 5), (2) social worker responsibilities (n = 11), and (3) policy dictates practice (n = 7). Future research ought to include primary data collection methods with NH social workers, as well as NH residents and family, as residents must be at the center of their care. Considering policy modifications to further enhance the social work role of the interdisciplinary team is warranted.

Exploring Patterns in Preferences for Daily Care and Activities Among Nursing Home Residents

Nursing homes have shifted from task-focused to person-centered care (PCC) environments. Understanding resident preferences for daily care and activities is fundamental to PCC. Examining resident similarities based on preferences may be useful for group or community-wide PCC planning. The aims of the current study were to group residents according to similarities in preferences and determine the factors that predict membership in these groups. A latent class analysis of resident preferences using data from the Minimum Data Set (N = 244,718) was conducted. Resident function, depression, cognitive impairment, and sociodemographics were used as predictors of class membership. The four-class model showed residents cluster around overall interest or disinterest in having choices about daily care and activities or specific interest in either care or activity preferences. Race and ethnicity, cognitive impairment, and depression predicted class membership. Findings suggest that residents can be grouped by preferences and knowledge of resident group membership could help direct efforts to systematically meet resident preferences. [Journal of Gerontological Nursing, 45(8), 7-13.].

Preparedness of representatives for people with dementia in a self-directed program

Representatives enact their role as decision-making partners across the intersection of participant direction (PD) and dementia care. Self-rated preparedness for key dimensions of the role endorsed by a panel of experts in PD and dementia was assessed by telephone survey of 30 representatives of persons with dementia in a PD program. The sample (daughters 60%; Black 50%; rural 70%) was diverse in length of time in the role and additional responsibilities. They represented participants with moderate to advanced dementia and ≥ two additional chronic illnesses. Overall preparedness scores were in the pretty well to very well prepared range, with variation across dimensions and between individuals. Preparedness varied according to what has to be done day-to-day in dynamic or unpredictable situations, gauging decisional capacity, anticipating changing needs, ensuring safety, supporting a dementia-capable care team and negotiation. Stress was related to having a safety net of capable back-up supports and dementia care literacy. Areas of strength, individual variation and particular challenges along the trajectory of representing can guide development of support counselor interventions to provide representatives with tailored training and resources as they enable the benefits of PD for persons with dementia.

Home and Community-Based Service Use by Vulnerable Older Adults

Purpose of the Study

The purpose of this study was to identify different types of clients who use home and community-based services.

Design and Methods

Enrollment characteristics of 76 clients at risk of nursing home placement and Medicaid spend-down who were enrolled in the Virginia Community Living Program were analyzed. Two-step cluster analysis identified 4 groups of service users.

Results

Enabling resources (caregiver relationship to participant, participant living arrangement, and length of time caregiver provided assistance to participant) and disability type (physical, cognitive, traumatic brain injury, or other) differentiated the client groups. Groups differed on average service cost per day and likelihood of nursing home placement if services were not provided.

Implications

Findings point to the value of having practitioners assist vulnerable clients in tailoring services to meet different care needs and the need for refining policies guiding home and community-based care.

An interesting phenomenon in immigrant spouses and elderly suicides in Taiwan

BACKGROUND

Immigration is a global issue. Taiwan has a high proportion of immigrant spouses who take care of the aging parents-in-law at home mainly based on filial piety. Difficulties in communication in many aspects of daily life occur between the elderly and immigrant spouses, and result in the elderly becoming vulnerable and thus, influencing their psychological well-being. Although past studies demonstrated that due to cultural differences, employed foreign care providers negatively influenced elder care quality (e.g., care receipts' health or mortality rates), no studies have explored whether immigrant spouses, as family caregivers, have any influence on elderly suicides due to cross cultural communication differences.

OBJECTIVE

To address the above gap, this study was to examine the static relationship between immigrant spouses and elderly suicides.

METHOD

National-level authority data, comprising a 10-year longitudinal nationwide sample, were used. The number of immigrant spouses was treated as a proxy of cultural differences. Twelve models of outcomes with and without city- and time-fixed effects were conducted using panel data analysis.

RESULTS

Descriptive statistics of the study variables are provided. The results revealed that overall the number of immigrant spouses had a positive correlation with suicides in older adults. Further, the gender of immigrant spouses had different impacts on elderly suicides.

CONCLUSIONS

This is the first study to examine relation between immigrant spouses and the elderly suicides. The study results provide another viewpoint of understanding of the role of immigrant spouses in elder care, while promoting elder-caregiver interactions for optimal elder health outcomes.

A Review on Community-Based Knowledge Transfer and Exchange (KTE) Initiatives for Promoting Well-Being in Older Adults

Knowledge transfer and exchange (KTE) processes can facilitate evidence-informed community-based care for seniors, but understanding effective KTE in gerontology is limited. A scoping review was conducted to evaluate the current state of KTE in the community-based sector for seniors. Twelve articles met the inclusion criteria, which addressed a broad variety of topics including caregiving, elder abuse, falls prevention, home-rehabilitation, hospice and dementia care. Studies evaluated KTE practices (n = 8), developed a KTE intervention (n = 3), or explored research uptake (n = 1). Community-based initiatives for seniors informed by KTE processes are scarce, requiring further efforts at the research, practice and policy levels.

Factors related to satisfaction with long-term care services among low-income Korean elderly adults: A national cross-sectional survey

BACKGROUND

With the growing demand for long-term care (LTC) services, it is increasingly important to explore experience with care. This study examined care satisfaction in a nursing home and at home among low-income elders in South Korea.

METHODS

This cross-sectional study was conducted with 246 elderly recipients of welfare benefits using a proportional stratified sampling method. Two self-reported versions of a questionnaire developed for users of nursing home care and homecare were used.

RESULTS

Those at home reported higher care satisfaction than those in nursing homes did. Both users of nursing home care and homecare were less satisfied with the food served. Users of nursing homes had comparatively less satisfaction regarding the daily activities available to them and less autonomy concerning their care decisions. Factors that influenced satisfaction with nursing home care and homecare were the quality of caregivers, care facilities, and physical wellbeing.

CONCLUSIONS

An approach focused on improving the quality of the care facilities and caregivers could help enhance care satisfaction among low-income Korean elders receiving LTC.

Exploring experience and perspectives of foreign-born direct care workers in dementia care: Accounts of Korean American personal care aides caring for older Korean Americans with dementia symptoms

This focus group study explored experience of Korean American personal care aides caring for older Korean Americans with dementia symptoms. Personal care aides described dementia caregiving as challenging, demanding and stressful, yet they cared for their clients with love and affection, particularly with jeong (i.e., a Korean cultural concept of love, affection, sympathy, and bondage). They learned about dementia mostly through their caregiving experience and expressed their need and strong desire to learn more about dementia. They felt for family struggle and observed family conflict and filial obligation. They advocated the value of personal care aides' involvement in dementia care. This study revealed a pressing need for dementia training for personal care aides and called for an outreach effort to recruit and train direct care workers with potential of providing culturally competent care for traditionally underserved ethnic minorities.

Impact of care settings on residents' functional and psychosocial status, physical activity and adverse events

BACKGROUND

Internationally, as the number of older adults increases, different types of care settings are evolving to address the care needs of this growing group of individuals.

AIMS AND OBJECTIVES

The purpose of this study was to describe and compare clinical outcomes of residents with moderate to severe cognitive impairment living in residential care facilities (RCFs) and nursing homes (NHs).

DESIGN

This was a secondary data analysis that included data from two studies testing a Function-Focused Care for Cognitively Impaired (FFC-CI) Intervention.

METHODS

A total of 96 participants were from RCFs and 103 were from NHs. Change scores over a 6-month period in RCF and NH residents were evaluated using a multivariate analysis of variance.

RESULTS

Residential care facilities residents had more agitation, better function and engaged in approximately twice as much physical activity as those in NH settings at baseline. Controlling for treatment status and baseline differences, over 6 months, RCF residents showed a decrease of -22.77 ± 41.47 kilocalories used in 24 hours while those in NHs increased to a mean of 10.49 ± 33.65 kilocalories used. With regard to function, residents in RCFs declined 10.97 ± 18.35 points on the Barthel Index, while those in NHs increased 10.18 ± 19.56 points.

CONCLUSIONS

In this sample, NH residents were more likely to be African American, had more comorbidities, less cognitive impairment, engaged in less physical activity, were more impaired functionally and had less agitation than those in RCFs. Controlling for treatment group status and baseline differences in comorbidities, cognitive status and race, residents in RCFs declined more in terms of functional and physical activity over a 6-month period.

IMPLICATIONS FOR PRACTICE

Ongoing research and clinical work is needed to understand the impact of care settings on clinical outcomes.

Listening to the voices of native Hawaiian elders and ‘ohana caregivers: discussions on aging, health, and care preferences

Native Hawaiians, the indigenous people of Hawai’i, are affected by varying social and health disparities that result in high prevalence of chronic disease, early onset of disability, and shorter life expectancy compared to other ethnic groups in Hawai’i. Six listening meetings were conducted, involving 41 community-dwelling kūpuna (Native Hawaiian elders) and ‘ohana (family) caregivers to investigate health and care preferences that offer the potential for improving well-being in later life for Native Hawaiian elders. As background, we provide three explanatory perspectives and theories—life course perspective, minority stress theory, and historical trauma—that guided the design of this study and provided the study’s context. A number of overarching themes and subthemes were identified, some of which point to universal concerns with age and caregiving (such as challenges and costs associated with growing old and caregiving) and others that are culturally specific (such as influence of culture and social stressors, including discrimination, on health needs and care preferences). Results give further support to the urgency of affordable, accessible, and acceptable programs and policies that can respond to the growing health and care needs of native elders and family caregivers.

Foreign-born care givers in Washington State nursing homes: characteristics, associations with quality of care, and views of administrators

OBJECTIVE

Following national trends, Washington State relies heavily on foreign-born workers to provide long-term care. Our study assesses state nursing facility characteristics, quality ratings, and the views of facility administrators about the implications of an increasing number of foreign-born employees.

METHODS

We used independently available data to supplement a survey of nursing home administrators.

RESULTS

Nearly half of the administrators reported difficulty hiring U.S.-born job applicants. Three in four administrators reported problems related to language differences, and just more than a third reported challenges related to cultural and/or religious differences. Nonetheless, the proportion of foreign-born employees was positively associated with independent facility quality ratings. Almost half of the administrators reported discrimination by patients/clients toward their foreign-born workers. Quality ratings were negatively associated with for-profit, chain, or multi-ownership status.

DISCUSSION

The proportion of foreign-born employees in nursing facilities may be associated with improved performance.

Getting on with living life: experiences of older adults after home care

Providers in all settings are increasingly aware of the need to focus on transitional care needs and services across healthcare settings to improve quality of life, maintain optimal health, and prevent unnecessary hospitalizations. Home care is an essential piece of the transitional care puzzle, especially in providing services to support older adults with chronic comorbid conditions to remain at home safely with optimal health and psychosocial well-being. Home care is essential in bridging the gap from acute hospital care to home; however, little is known about the needs of older adults after discharge from home care. Our study investigated the perceptions of older adults with chronic health conditions after discharge from home care regarding their daily activities and healthcare needs and identified how these needs were met.

A Model of Risk Reduction for Older Adults Vulnerable to Nursing Home Placement

Because of the cost of nursing home care and desire of older adults to stay in their homes, it is important for health care providers to understand the factors that place older adults at risk for nursing home placement. This integrative review of 12 years of research, as published in 148 articles, explores the risk factors for nursing home placement of older adults. Using the framework of the vulnerable populations conceptual model developed by Flaskerud and Winslow (1998), we explored factors related to resource availability, relative risks, and health status. Important factors include socioeconomic status, having a caregiver, the availability and use of home- and community-based support services, race, acute illness particularly if hospitalization is required, medications, dementia, multiple chronic conditions, functional disability, and falls. Few intervention studies were identified. Development of evidence-based interventions and creation of policies to address modifiable risk factors are important next steps.

Primary Care Physicians’ Attitudes Regarding Collaborating With Home-Based Depression Care Managers

Home-based case managers face many challenges to collaborating with primary care physicians, including for management of depression. To obtain physicians’ perspectives regarding optimal collaboration strategies, we conducted a mail survey of randomly selected primary care physicians ( N = 74). The survey described a home-based depression care management program to be delivered by case managers and assessed physicians’ preferred collaboration strategies. Most respondents perceived the services described as useful, including having the case manager send a list of medications and send psychotropic medication recommendations per consulting psychiatrist. Most physicians reported being likely to read a written summary sent by the case manager, reply, and send it back to the case manager. Preferred communication procedures varied widely. By considering physicians’ preferences, case managers may enhance collaboration.

Consumer direction in long-term care policy: overcoming barriers to promoting older adults' opportunity for self-direction

There has been a growing trend in long-term care policy to offer individuals with disabilities the option of consumer direction (CD), where responsibility of managing care and support services is transferred from agencies to care recipients, thus supporting clients' self-determination. Although CD has been accepted as an option for non-elderly individuals with disabilities, barriers persist to promoting older adults' autonomy through CD. This article reviews the incorporation of CD in long-term care policy, addresses the current barriers to providing older adults the right to self-direct, and makes recommendations for overcoming these barriers through social work practice, policy, and research.

Promoting personalization in social care services for older people

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.

Why Are Native Hawaiians Underrepresented in Hawai'i's Older Adult Population? Exploring Social and Behavioral Factors of Longevity

Native Hawaiians comprise 24.3% of Hawai'i's population, but only 12.6% of the state's older adults. Few published studies have compared health indicators across ethnicities for the state's older adult population or focused on disparities of Native Hawaiian elders. The current study examines data from two state surveillance programs, with attention to cause of death and social-behavioral factors relevant to elders. Findings reveal that Native Hawaiians have the largest years of productive life lost and the lowest life expectancy, when compared to the state's other major ethnic groups. Heart disease and cancer are leading causes of premature mortality. Native Hawaiian elders are more likely to report behavioral health risks such as smoking and obesity, live within/below 100-199% of the poverty level, and find cost a barrier to seeking care. Indicated is the need for affordable care across the lifespan and health services continuum. Future research might explain behavioral factors as influenced by social determinants, including historical trauma on Native Hawaiian longevity.

The Tokyo Oldest Old survey on Total Health (TOOTH): a longitudinal cohort study of multidimensional components of health and well-being

Background

With the rapid worldwide increase in the oldest old population, considerable concern has arisen about the social and economic burden of diseases and disability in this age group. Understanding of multidimensional structure of health and its life-course trajectory is an essential prerequisite for effective health care delivery. Therefore, we organized an interdisciplinary research team consisting of geriatricians, dentists, psychologists, sociologists, and epidemiologists to conduct a longitudinal observational study.

Methods/Design

For the Tokyo Oldest Old Survey on Total Health (TOOTH) study, a random sample of inhabitants of the city of Tokyo, aged 85 years or older, was drawn from the basic city registry. The baseline comprehensive assessment consists of an in-home interview, a self-administered questionnaire, and a medical/dental examination. To perform a wide variety of biomedical measurements, including carotid ultrasonography and a detailed dental examination, participants were invited to our study center at Keio University Hospital. For those who were not able to visit the study center, we provided the option of a home-based examination, in which participants were simultaneously visited by a geriatrician and a dentist. Of 2875 eligible individuals, a total of 1152 people were recruited, of which 542 completed both the in-home interview and the medical/dental examination, with 442 completed the in-home interview only, and another 168 completed self or proxy-administered data collection only. Carotid ultrasonography was completed in 458 subjects, which was 99.6% of the clinic visitors (n = 460). Masticatory assessment using a colour-changeable chewing gum was completed in 421 subjects, a 91.5% of the clinic visitors.

Discussion

Our results demonstrated the feasibility of a new comprehensive study that incorporated non-invasive measurements of subclinical diseases and a detailed dental examination aiming at community-dwelling individuals aged 85 years or older. The bimodal recruitment strategy is critically important to capture a broad range of health profiles among the oldest old. Results form the TOOTH study will help develop new models of health promotion, which are expected to contribute to an improvement in lifelong health and well-being.

Trial Registration

This study has been registered in the UMIN-Clinical Trial Registry (CTR), ID: UMIN000001842.