1042072

research-article2021
TCNXXX10.1177/10436596211042072Journal of Transcultural NursingIrie et al.

Research

Journal of Transcultural Nursing

Culturally Congruent Health Activities for

2022, Vol. 33(1) 16­–25
© The Author(s) 2021
Article reuse guidelines:
the Prevention of Functional Disabilities sagepub.com/journals-permissions
DOI: 10.1177/10436596211042072
https://doi.org/10.1177/10436596211042072

Among Older Adults in Japan’s Forest journals.sagepub.com/home/tcn

Communities

Yasuko Irie, PhD, RN, PHN1 ,

Naohiro Hohashi, PhD, RN, PHN, FAAN1 ,
Shunji Suto, PhD2, and Yu Fujimoto, PhD3

Abstract
Introduction: In Japan’s forest areas, cultural capital and older adults play key roles in helping to sustain the community.
The purpose was to explore cultural values/beliefs related to culturally congruent health activities among older adults
in forest communities. Method: The qualitative ethnonursing research method was used. Data were collected through
fieldwork and key informants’ interviews (n = 14) over 1 year. The setting was a traditional village with 80% forest cover.
Results: Findings included two universal cultural values/beliefs, which were “community identity as a community member”
and “our cohesion and connection as community members.” Additionally, two diverse cultural values/beliefs were found:
“gender-based differences” and “differences between those having experience working outside the forest community and
those without this experience.” These were related to community-based health activities. Discussion: These values/beliefs
were suggested to develop a multilayered network around health activities in order to prevent functional disabilities among
older adults.

Keywords
qualitative ethnonursing research, community health, culturally congruent heath activities, Japan’s forest community,
prevention of functional disabilities

Introduction depopulation due to factors such as declining birthrate,

aging population, deterioration in lumber and agricultural
According to the World Health Organization (2018), for the production (dating from around 1960), and, more recently,
first time in history, worldwide human life expectancy has increased marginalization (Miyashita, 2020). Currently,
extended beyond 60 years. Japan’s population is aging at an older adults in Japan’s forest communities have difficulty
unprecedented rate, with the percentage of those aged 65 years carrying out routine functions in their daily lives. However,
and above projected to reach 30.3% of the total population by many older adults regularly engage in sports as a health
2025 (National Institute of Population and Social Security activity aimed at preventing functional disabilities. Forest
Research, 2019). Among residents of Japan’s forest communi- communities possess important cultural resources such as
ties, more than half the population is aged 65 years and older, religious shrines and temples, the history of which in some
and those in this segment confront various difficulties main- cases extends back well over 1,000 years. These shrines and
taining adequate functioning in daily life. In recent years, the temples nurture and maintain bonds among community
approach to preventive health care policies for older adults has
expanded from identifying health problems, such as physical
1
Kobe University, Kobe-shi, Hyogo, Japan
functional disabilities and nutritional deficiencies, to utilizing 2
Nara Medical University, Kashihara-shi, Nara, Japan
a proactive community-based approach aimed at preventing 3
Nara University, Nara-shi, Nara, Japan
functional disabilities. Within these communities, cultural
Corresponding Author:
capital and older adults play key roles in helping the commu-
Yasuko Irie, PhD, RN, PHN, Researcher, Division of Family Health Care
nity sustain itself over time (To & Chong, 2017). Nursing, Graduate School of Health Sciences, Kobe University, 7-10-2
Roughly two-thirds of Japan’s total land area is cov- Tomogaoka, Suma-ku, Kobe-shi, Hyogo 654-0142, Japan.
ered by forests. Japan’s forest communities are facing Email: [email protected]
Irie et al. 17

members. According to Shinno (2016), older adults in based on population census and other statistical data. The
Japan’s forest communities regularly attend cultural cere- domain of inquiry was community-based health activities to
monies, thus strengthening their group cohesiveness and prevent functional disabilities among older adults, as well as
personal interrelationships. cultural values and beliefs of older adults living in one of
A recent ethnographic study of older adults living in a Japan’s forest communities.
rural community on an isolated Japanese island highlighted
unique beliefs and activities aimed at connecting the com-
Research Setting
munity (Kawasaki, 2018). In light of this, drawing on the
cultural value of Yui, meaning a tie/bond to a community, The research setting was a traditional village with around 80%
may help community health care providers, including public forest cover and a history dating back more than 1,000 years.
health nurses, promote culturally congruent health activities The village includes 37 cohesive communities (i.e., small
for older adults in Japan’s forest communities. However, regional units). Its population has greatly decreased from
limited studies have been conducted on the cultural values 15,182 in 1960 to 6,868 in 2019. In 2015, households with
and beliefs of these communities. older adults aged 65 years and above accounted for 74.0% of
Leininger defined culture as “the learned, shared, and all households, and 25.8% of these were single-member
transmitted values, beliefs, norms, and lifeways of a particu- households. In 2019, the percentage of residents aged 65 years
lar culture that guide thinking, decisions, and actions in pat- and older was 53.7%, with a male to female ratio of 1:1.3. It is
terned ways (McFarland & Wehbe-Alamah, 2019, p. 546). important to note that this particular community has held com-
Because culture plays a key role in social contexts (i.e., munity-based sports activities, and the older adults have been
regarding individual behaviors), cultural background has an regularly playing ground golf and engaging in other health-
impact on health care. Many older adults in Japan are imbued related activities for more than a decade. Ground golf is a form
with various cultural and ethnic traditions that diverge con- of recreation developed in Japan, in which players using
siderably from members of the younger generation. As they implements similar to golf balls and golf clubs compete to
age, culturally congruent health care is essential not only for place their ball into a post hole in as few strokes as possible.
older adults but also for their families and community mem-
bers (Cuellar, 2015).
Data Collection and Data Analysis
Data collection was performed based on ethnonursing
Theoretical Framework research method, and Leininger’s Stranger to Trusted Friend
The theoretical framework of this study is based on Leininger’s Enabler was employed, which indicates how nurses transi-
theory of culture care diversity and universality (McFarland tion from strangers to trusted friends to obtain accurate,
& Wehbe-Alamah, 2019), to explore how the cultural values/ in-depth, and reliable data (Wehbe-Alamah, 2018b). The
beliefs of older adults can be considered when promoting fieldwork was performed from 2019 to 2020. Concurrent
culturally congruent health activities for the prevention of data collection and analysis were completed using the
functional disabilities. This theory holds that for care to be Leininger’s Four Phases of Ethnonursing Data Analysis
culturally congruent, culture and care are interdependent and Enabler (Wehbe-Alamah, 2018b). The first phase included
intertwined and that culturally appropriate nursing care is raw data such as field observations, informal interviews, and
“culturally meaningful, therapeutic, congruent, and safe for data from the population census; the second phase consisted
people of diverse and similar cultures” (McFarland & Wehbe- of verbatim remarks obtained from key informant interviews.
Alamah, 2015, p. 5). Data analysis at this point involved concurrently collecting,
The purpose of this study was to explore cultural values/ coding, categorizing, and interpreting the information. The
beliefs related to culturally congruent health activities among codes from the informal interviews and key informant inter-
older adults in Japan’s forest communities, by addressing views were then grouped into categories by similarity. In the
two research questions: (1) What are the cultural values and third phase, similar or related codes were grouped into cate-
beliefs of older adults in this particular forest community? gories, which were subsequently developed into broad
(2) How do these cultural values and beliefs relate to com- themes and identified patterns. In the fourth and final phase,
munity-based health activities? representative narratives that effectively described each
theme were selected.
Method
Approach to Gatekeepers
Leininger’s qualitative ethnonursing research method was
used, as designed in Leininger’s theory of culture care diver- The gatekeepers were approached through a researcher’s
sity and universality. The method consists of field observa- friend, who was a public health nurse, to gain permission to
tions, informal interviews with older adults, formal interviews perform the fieldwork. The gatekeepers included the heads
with key informants, and determining community conditions of the health center and community sports club.
18 Journal of Transcultural Nursing 33(1)

Field Observation Table 1. Key Informant Demographics (n = 14).

More specifically, the health center and community sports Characteristics N
club, as well as the community grounds, were observed for 3
Age by decade
hours each week (2 days per week, on average) over 7 months
60s 1
to determine the users’ cultural values and beliefs. About 100
70s 9
older adults approached in 16 community health activities
80s 4
and five community health meetings were interviewed in the Gender
informal interviews. The observations and informal inter- Male 11
views were conducted in familiar or natural cultural contexts Female 3
in one of the following four ways: (1) observation without Marital status
participation, (2) observation with limited participation, (3) Married 14
participation with continued observation and informal inter- People in household
views, and (4) reflection on the key informant interviews. We 2 10
compiled memos on what observers heard and saw, as well 3-4 4
as their impressions, thoughts, and others. Visual data were Highest educational level
also collected through photography, mapping, and sketching. High school 10
All these data were compiled to produce the fieldnotes. University or college education 4
Working outside forest community
Having experience 4
Key Informant Interview Not having experience 10
Formal interviews were held with key informants approxi-
mately 4 months after commencement of the observation
phase. Purposive sampling and the snowball method were accomplished based on Leininger’s Observation-Participation-
used to recruit key informants. Data were collected through Reflection Enabler and Leininger’s Stranger to Trusted Friend
face-to-face, open-ended interviews and semistructured Enabler in familiar or natural cultural contexts. (3)
interviews, based on an interview guide prepared in advance, Transferability and recurrent patterning were established by
by two researchers, one outsider (i.e., the etic perspective) having two gatekeepers verify that the results of the analysis
and another insider (i.e., the emic perspective). The infor- fit the data from the participants’ experiences and lifeways.
mant interviews were audio-recorded and transcribed verba- (4) Data saturation was confirmed, as categories and patterns
tim in Japanese. The interview started with the following emerged and the observations and interviews no longer pro-
general questions: Would you talk about a symbolic cultural duced new information.
event in your daily life? What is the reason you chose this
cultural event? Is the cultural event continuing currently? Ethical Considerations
How is the event run and what is it like in terms of the num-
ber of people, gender roles, and so on? What influence does This study was reviewed and approved by the institutional
the cultural event have on people’s way of life, values, or review board of the researchers’ university. The study objec-
beliefs? How have people’s values changed recently? What tives, methods, reasons for audio recording, right to with-
do you think about these recent changes in values or beliefs? draw, and protection of personal data were explained to the
What do you think about preventing functional disabilities key informants in both verbal and written form. During the
among older adults by drawing on the perspective of cultural fieldwork, the right to withdraw and the protection of per-
values and beliefs? sonal data were verbally explained to the participants.
Table 1 shows demographics of 14 key informants for for-
mal interviews, including older adults who were native to the
community and aged 60 years and older. The key informant
Results
interviews were conducted at home (8), the health center (2), Four themes, 10 patterns, and 10 categories that influenced
an office (2), and the community center (2). The mean inter- older adults’ health-related activities, were extracted (see
view duration was 72 min (SD = 19; range: 45-110). Table 2). These consisted of two universal themes, referring
to commonalities and similarities within cultural values/
beliefs, and two diverse themes, referring to the differences
Method Consideration
or variabilities within cultural values/beliefs. These cultural
The criteria for the substantiation of ethnonursing research values/beliefs that were inculcated during childhood and
(Wehbe-Alamah, 2018b) were considered. (1) Credibility adolescence had a long-term impact on their lives and were
was substantiated through both the emic and etic and debrief- related to community-based health activities. Among health-
ing phases. (2) Confirmability and meaning in context were related activities, ground golf had the highest number
 Table 2. Summary of Findings on Cultural Values/Beliefs of Older Adults (Formal Interviews: n = 14, Informal Interviews: n = approximately 100).
Universal or diverse theme Major themes Patterns Identified categories Identified subcategories

Universal theme Experiencing community We hold community health Cultural belief in community We protect our symbolic place of culture.
identity through cultural activities in the milieu of psychological boundaries We trust in the leader of our community.
activities is a reason for community psychological We have programs every week for older adults at the
continuing to participate boundaries. community base.
in community-based health Our community means not only geographic spaces but also
activities. psychological boundaries.
We have performed cultural Cultural value of community We have participated in community cultural events with
events in the community with membership community members.
community members. We change the means but carry on with community cultural
events that our ancestors held.
My cultural beliefs and self- Cultural belief in self- My own community identity helps in a community crisis.
community identity affect my community identity We participate in cultural events based on our community
participation in community identity.
health activities.
We enjoy time together during Cultural value of enjoying I still earn money to enjoy sports.
community-based heath time together I looked forward to participating in community-based health
activities. activities while in the hospital.
Community-based heath I believe in our community Cultural belief in our Community members have affectionately watched children as
activities relate to building cohesiveness; therefore, I cohesiveness the community’s young people grow up with confidence.
community capacity from will participate in and enjoy I have seen adults participate in community cultural events
our cohesiveness or community heath activities. since childhood.
connection as community The whole community watches the life of a child.
members. I value that every older adult Cultural value of connection I respect a person older than myself, so I cannot address him
should participate in a senior of the community or her by a nickname.
community club because I hold members I appreciated the help of community members at family
a cultural value of connection of funerals.
the community. I do not like actions that disturb local cohesiveness.
I have close relationships with people, and we can call each
other by nicknames now.

(continued)

19
20
Table 2. (continued)

Universal or diverse theme Major themes Patterns Identified categories Identified subcategories

Diverse theme We enjoy time together We enjoy spending time together Cultural value of both I enjoy spending time with congenial people and value
with congenial people from with congenial people from community-based community connections.
different communities different communities. relationships and enjoying I have made new friends with other graduates of my
or in community-based spending time with elementary and junior high school in my old age.
relationships. congenial people (among I value having acquaintances across a larger section of a
females) community.
I value equal relationships.
I value independence.
We enjoy spending time with Cultural value of I watch over my ancestral land (called tsuchi in Japanese).
people in community-based community-based Community cultural events are a topic that we communicate
relationships. relationships (among about daily.
males) I take responsibility as an eldest son.
I value community-based relationships.
“Our” or “my” I take action with “my” Cultural belief in “my” Even if something is not obligatory, if I judge that it should be
competencies create competencies, which is competencies (among done, I do it.
community-based health necessary for the community those having experience of I hold a cultural value of self-reliance.
activities. activities concerned. working outside the forest
community)
We take actions with “our” Cultural belief in “our” We judge what it is necessary for community action and take
competencies, which are competencies (among action together.
necessary for participating in those having no We not only enjoy but also help each other in community
community activities. experience of working leisure.
outside the forest I cannot participate in community events where I am not
community) personally involved in the preparations.
Irie et al. 21

of participants and reflects the cultural influence of forest influenced them to participate in community-based health
communities. Ground golf was organized into three types activities. One formal interview subject stated the
(congenial people ground golf, community ground golf, and following:
nonprofit organization sports club), with the ratio of male
and female participants approximately the same. Other When I was 19, my mother died, and three months later, my
health-related activities were “gateball” and “an exercise grandmother died. At that time, my community members helped
program to live a vibrant life until 100 years old.” About 10 me with everything from holding the funerals to preparing
years ago, many elderly adults had begun to participate in graves for the burials. Now, the funeral ceremony has changed,
and help from community members is no longer necessary.
sports from gateball to ground golf. The exercise program
However, I will never forget the help that I received. I thought
refers to policy-based physical exercise program as provided older adults don’t like anything selfish because it can disturb the
by national law. community cohesion or connection of community members.
Therefore, I still strongly appeal to community members for
Universal Theme 1: Experiencing a community identity their participation in community-based health activities and
through cultural activities is a reason for continuing to cultural events.
participate in community-based health activities.
This theme represents our cohesiveness and connection of
All key informants mentioned having a sense of community the community members, and older adults in the past found
identity that influenced their participation in health-related ways to establish these. The majority of male participants
activities. Similar responses included community psychologi- mentioned the funeral ceremony, and most male participants
cal boundaries, community membership, a self-community also said that they generally led cultural events. On the other
identity, and enjoying time together. One formal interview hand, the majority of female participants took supporting
subject stated the following: roles for their husbands during cultural events in the com-
munity. For example, at a popular event at the shrine, called
We have attended many cultural events at this temple since gokumaki in Japanese, men scatter rice cakes that have been
childhood. When I was a child, I ate celebratory red rice with offered to the deities among community members. Most
many older adults and listened to stories about various historical female participants said that they prepared rice cakes for the
events. I still remember the taste of the red rice. Now, when event, but women do not scatter them. The majority of female
climbing the steep stairways to the temple, we feel our age.
participants did not feel a sense of discomfort in this situa-
However, we still spend our time cleaning the temple and holding
tion and accepted this community norm. The majority of
weekly health programs for older adults in our community (e.g.,
physical exercise training group). both male and female participants expressed the cultural val-
ues of community cohesiveness and connection of the com-
This indicates that older adults participated in various cul- munity, and although the community’s population declined,
tural and health-related activities to build their sense of iden- older adults have continued to hold cultural events and com-
tity in the community. They explained that their children no munity-based health activities for at least a decade.
longer lived in the community and that they would likely be
the last generation living there. Even so, they carried on cul- Diverse Theme 1: We enjoy time together with congenial
tural events every month. This was because they experienced people from different communities or in community-
the events not only as cultural traditions but also as opportu- based relationships.
nities for learning about community psychological boundar-
ies and community membership from the stories of various The female participants tended to value both community-
based relationships and enjoying spending time with conge-
community members.
nial people. In some cases, female participants would
They accepted that community life was difficult to sustain
venture into different communities to participate in health-
due to depopulation and realized a self-community identity
related activities with other older adults. However, the
through cultural events. They held programs every week and
majority of male participants valued community-based rela-
played ground golf twice a week at the community temple
tionships only. A female informal interview subject stated
(their symbolic place of culture) as a community-based
the following:
health activity to prevent functional disabilities. They were
enjoying time together with each other.
Sometimes, a friend and I would leave the community and meet
older adults from a different community. For example, we did
Universal Theme 2: Community-based heath activities this when we could not play ground golf on our community’s
relate to building community capacity from our cohesive- course. So while I understood community boundary, I simply
ness or connection as community members. searched for ground golf courses in different communities and
selected the course on which we wished to play.
All the formal interview subjects described the cohesion and
connection as a community of older adults, as well as how it A male formal interview subject stated the following:
22 Journal of Transcultural Nursing 33(1)

I take responsibility for safeguarding my ancestral land competencies, which are group-focused community cooper-
(expressed as tsuchi in Japanese), which I view as being my ation abilities, and “my” competencies, which are personally
native and sacred soil. The eldest son must protect the ancestral focused individual abilities, in creating community-based
house and mountain from generation to generation. Incidents of health activities. They did not, however, discuss this matter
damage by wild boars have spread. People say that our lives
between themselves and treated the differences between
have become more constrained due to the wild boars’ damage,
“our” or “my” competencies as a taboo. This theme indicates
and marginalization is becoming a problem. However, I (as an
eldest son) take responsibility for safeguarding this land; how the community members performed certain activities.
therefore, community-based relationships are important to me. “Our” or “my” competencies are regional sayings, wagairade
or wagame in Japanese. All older adults were familiar with
This theme represents how older adults in the community these, which referred to differences between those having
enjoy spending time with congenial people, even with those experience of and those having no experience of working out-
from different communities. When multiple communities get side the forest community. Those not having experience refers
together for a sporting event, the men tend to sit with mem- to “our” competencies: The older adults had previously
bers of their own community. However, the women tend to worked in local industries such as forestry or agriculture and
mix with congenial people from different communities. The regarded “our” community cooperation as a cultural value.
women valued community-based relationships and con- Those having experience refers to “my” competencies: One
nected with others through the women’s society or parent- participant had been an office worker until retirement and
teacher association activities. They also enjoyed being with held “my” self-reliance as a cultural value. Thus, the concept
congenial people, including having freedom from control by of “our” or “my” competencies influenced the building of
community members and being able to make their own deci- more enriching community-based health activities.
sions in life, reflecting the cultural value of independence.
This theme of congenial people did not appear in the inter- Discussion
views with male participants. The male participants valued
community-based relationships and usually communicated Among older adults who participated in policy-based pro-
daily about community cultural events. grams (physical exercise, hobby activities, and others) devel-
oped by the government, which is aimed at preventing
Diverse Theme 2: “Our” or “my” competencies create functional disabilities in Japan, females (89.5%) consider-
community-based health activities. ably outnumbered males (10.5%; Health and Welfare Bureau
for the Elderly, Ministry of Health, Labour and Welfare,
The older adults made certain judgments regarding their Japan, 2018). In contrast, the male/female ratio of partici-
abilities in community-based health activities, such as differ- pants in this study of community-based health activities was
ences between those having experience working outside the approximately equal. In policy-based programs, only interest
forest community, which refers to “my” competencies, and in the program leads to participation behavior; hence, older
those not having experience, which refers to “our” compe- adults having little/lack of interest almost never become par-
tencies. For example, one informal interview subject stated ticipants. In terms of Japanese culture, males do not find
the following: such programs interesting (Okubo et al., 2005). Community-
based health activities in this study concern personal and
We determined that snacks were necessary for our round of interpersonal aspects as well as broader aspects at the com-
ground golf. So, we happily prepared the appropriate kitchen munity level. Community-based health activities are found
equipment and made some snacks. In this case, we performed to be created by both universal and diverse cultural values
these actions based on our abilities, which is the natural conduct and beliefs, and older adults believe that such activities are
of many community members. important not only as a source of fulfillment but also as a
specific strategy for developing appropriate sporting oppor-
Another formal interview subject stated the following: tunities as viable health-related activities. We could thus
establish two universal themes and two diverse themes,
This year I am going to retire from being the health activities which are discussed as follows.
leader, since I have held this position for two years. My
predecessor continued it for 10 years. . . . When the same person
is the leader for many years, the community health activities do Universal Cultural Values/Beliefs Related to
not change. Anyone can serve as leader. I was an office worker Culturally Congruent Health Activities
for a long time in various organizations. I think leaders should
not serve for extended terms. This is my own thought. It is a In mountainous areas of Japan, health activities are related to
judgment only for me, and not discussed with anybody else. a sense of pride among older adults, and their pride is main-
tained by the strength and support provided by friends
The older adults sometimes told the outside researcher (Omori, 2004). In rural communities on isolated islands of
(i.e., the etic perspective) about differences between “our” Japan, Yui, meaning a tie/bond to a community, is related to
Irie et al. 23

health among older adults (Kawasaki, 2018). This term The gender-based differences, cultural value of both com-
incorporates a sense of cohesiveness or connection as com- munity-based relationships and spending time with conge-
munity members and participation in community health nial people among females, prompted women to express
activities and relates to the universal theme of our study. diverse needs about community-based health activities, and
Thus, this theme is universal and essential to community- women organized ground golf or community-based health
based health activities. activities that brought together congenial people from differ-
Japan’s forest communities incorporate many shrines and ent communities. Community-based health activities to pre-
temples. Cultural events held at shrines involve not only reli- vent functional disabilities among older adults fall under
gious festivals but also activities by people who live in the social networks. Their cultural values and beliefs were main-
shrine area (Shinno, 2016). Because Japan was formerly a tained vertically from generation to generation through reli-
patriarchal society in which men generally headed their fam- ance on male leadership. However, gender-based differences
ilies and communities (Kato, 1994), cultural events con- were identified, and women valued both community-based
ducted vertically from generation to generation have relied relationships and spending time with congenial people.
on male leadership. The prohibition against women entering Women contacted older adults in different communities and
the inner shrine, called kegare culture in Japanese (Hashisako, replicated cultural values horizontally from person to person
2019), continues even today. Such patriarchal traditions, and created network hubs over time. This demonstrates the
especially regarding the festivals at shrines and temples, presence of not only community-based networks but also
which are organized as self-governing events, have contrib- different-community-based networks.
uted to the viewpoint by the majority of male participants In this background, the majority of male participants had
that sport-related health activities should be community- worked outside their forest community, as the community
based. These childhood and adolescent experiences at cul- had undergone depopulation (Miyashita, 2020). However,
tural events have influenced “cultural value of enjoying time they chose to return to their ancestral homes on retirement
together.” In this study, a majority of male participants raised because, according to social norms, the eldest son would suc-
the topic of funeral ceremonies, and their stories included ceed as head of the family (Meguro, 1991). Once they reset-
details not only about how funeral ceremonies were con- tled into their community, the men aimed to increase their
ducted but also about their experiences related to burials, community identity as a community member having had the
which imparted participants with a strong sense that the experience working outside the forest community. Not hav-
deceased person had lived his or her life to the fullest. These ing experience of working outside the forest community,
experiences could not be understood by some of the other referred to as “our” competencies, as opposed to having such
community members, among whom were older adults raised an experience, referred to as “my” competencies, results in
in communities. The majority of male participants frequently creation of different values among community members
talk to other community members and share their experi- regarding their way of life. The cultural value of self-reliance
ences with each other. This indicates that community-based (“my competencies”) and community cooperation (“our
health activities serve as opportunities for empathetic competencies”) encourage older adults to build further
encounters of cultural value, belief, and healing. Therefore, it enriching activities.
can be said that the presence of these universal cultural val- Previous studies have indicated that community-level
ues and beliefs motivate older adults to participate in com- social capital and social networks are important for older
munity-based health activities. adults in terms of health and well-being (Reeves & de Vries,
2019; Tsuji et al., 2018; Vaisey & Lizardo, 2010). Such social
Diverse Cultural Values/Beliefs Related to networks focus on the community as one layer. According to
Li et al. (2018), a community does not exist solely as a sin-
Culturally Congruent Health Activities gle-layered network with a single type of node and node
In this study, cultural diversity relates to providing beneficial interactions; it can also be presented in a multilayered fash-
care to clients of a specific culture. However, previous stud- ion. Thus, this study focused on cultural diversity among
ies (Kawasaki, 2018; Omori, 2004) neglected to identify cross-layered networks in different communities. As various
diverse themes, because those researchers consisted only of information sources exist in a multilayered network (Li et al.,
outsiders. Leininger pointed out the need to differentiate 2018), we were able to elucidate concerning elements of
between insiders and outsiders, and it was essential to deter- cultural diversity among older adults.
mine what was universal and what was different among Cultural diversity of gender-based differences and dif-
cultures with respect to care and caring (McFarland & ferences between the differences in “our” or “my” compe-
Wehbe-Alamah, 2019). Accordingly, we confirmed and dis- tencies were conducted within “culture space” (forest
cussed data while repeating the observations and interviews communities) and “chronological culture” (the life course)
with the focus on cultural diversity from both etic and emic and played a key role in these activities. Phillips et al. (2015)
perspectives. These diverse themes could lead to more cul- suggested that the considerable cultural diversity observed
turally congruent care for older adults of various cultures. among older individuals can be partially explained by
24 Journal of Transcultural Nursing 33(1)

differences in their locations (within time and space) during health-related activities, were identified. The former two
the phases of their lives, which essentially corresponds with concerned community identity, and cohesiveness or connec-
the findings of this research. The term cultural space refers tion as community members, which motivated older adults to
to the variation of cultures in the use of corporeal, visual, participate in community-based health activities. The latter
territorial, and interpersonal distance to others (Wehbe- two were characterized by gender-based differences, and dif-
Alamah, 2018a), and the term chronological culture refers to ferences between those having experience working outside
the process in which individuals learn various values and the forest community and those not having this experience,
beliefs through cultural events and take on new values and thereby making cultural diversity a determining factor in
beliefs in the course of their lives. Hence, it is important to health-related activities. These four cultural values/beliefs
consider “cultural spaces” and “chronological culture” when were constructed from transitions over the life course, as
developing culturally congruent health activities to prevent well as sociohistorical change. Hence, it is important to con-
functional disabilities among older adults. sider “cultural spaces” and “chronological culture” when
conducting culturally congruent health activities for the pre-
vention of functional disabilities among older adults.
Practice Implications
Japanese health care providers traditionally play a central Declaration of Conflicting Interests
role in developing programs through a top-down approach The author(s) declared no potential conflicts of interest with respect
(Yoshioka-Maeda, 2020). Recently, community health care to the research, authorship, and/or publication of this article.
providers have been arranging for a “community place” for
preventing functional disabilities (e.g., physical exercise Funding
programs or health-related activities). However, healing cul-
The author(s) disclosed receipt of the following financial support
tural value and belief are essential elements for preventing
for the research, authorship, and/or publication of this article: This
functional disabilities. Therefore, it is important for commu- work was supported in part by a Grant-in-Aid for Scientific
nity health care providers to consider the meanings of Research (C) from the Japan Society for the Promotion of Science
“community place” in spaces and the relationship between in Japan (Grant Number: JP18K10547).
“community place” and health in terms of culturally specific
dimensions. Overall, older adults believed that cultural ORCID iDs
events and health-related activities were mutually related.
Yasuko Irie https://orcid.org/0000-0003-4502-8894
Particularly, cultural diversity influenced various health-
related activities. The implication of this finding is that Naohiro Hohashi https://orcid.org/0000-0003-0520-7433
health care staff should not take a top-down approach to
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