Abstract
Objective
The author conducted a survey on social mutual aid and the social stimulative effect of older adults living in a rural district, and compared young old and old-old persons to clarify the roles of public health nurses in promoting community development.
Materials and Methods
A cross-sectional study based on Andersen’s Behavioral Model of Health Care Utilization was conducted with 2,500 residents aged 65 years or older of City A in Akita Prefecture. The study was conducted from April 8 to May 15, 2017. Participants were administered a questionnaire containing items on “social mutual aid in the rural district”. Responses were recorded on a Likert scale.
Results
As a result of factor analysis, the following four factors were extracted; [Blessing of a rural district and mutual help and assistance unique to a rural district], [Closeness of healthcare welfare service and family doctors in conjunction with their own health], [Decline of culture and community unique to rural districts accompanied by depopulation] and [Closeness of the town where they live]. Differences were observed in the closeness of social mutual aid and local societal stimulative effects, even between generations of old and old-old persons. In young-old persons, a negative correlation was observed between [Closeness of the town where they live] and other factors. In old-old persons, a negative correlation was found between [Decline of culture and community unique to rural districts accompanied by depopulation] and other factors.
Conclusion
Since not only individual health indices but also local social mutual aid, which relates to individuals’ influence on the construction of a Community-based Integrated Care System in a rural district, the author posits that a data collection and analysis system on social mutual aid would be beneficial for community development for older adults living in rural districts.
Keywords: rural district, social mutual aid, community improvement, public health nurse, Community-based Integrated Care System
Introduction
Farm villages in Japan are facing the challenges of an aging population. In addition to supporting each other in agricultural activities, these communities frequently engage in mutual social aid. These practices are believed to have originated from an agricultural background and involve various activities such as village cooperation, ceremonial events, waterway maintenance, and the establishment of autonomy and consensus through resident assemblies and associations1). A farm village is an area with a low population density, abundant secondary natural surroundings from agriculture and forestry, and public resources such as land and water. A significant portion of land in these villages is utilized for agricultural and forestry purposes.
To build a community-based integrated care system2) considering the regionality of a farm village, objectively evaluating the mutual assistance and public help function is important for prompting the community development for which they are fully utilized. Public health nurses should more strongly recognize the “promotion of self-assistance and mutual assistance” and “improvement of local activities”3). Most older adults in farm villages build various networks based on the traditional relations of neighborhoods and families. A mutual aid system and self-assistance are combined functions in the lives of older adults in farm village areas4). This study aimed to outline the context of social mutual aid within a farm village and clarify the significance of collecting and analyzing such data, particularly for public health nurses striving to enhance community welfare.
Materials and Methods
Outline of the survey region: a city in Akita Prefecture
City A has a population of slightly less than 28,000. Its key is industrial agriculture, and the regionality of the farm village is clear, including its group- and local-level characteristics. Moreover, it received the Creative City of Culture and Art Promotion Project5) and the Discover Agricultural, Mountain, and Fishing Village Special Award6), indicating that it is a characteristic farm village. Thus, the entirety of City A was surveyed as a farm village region.
Study design
This study used a cross-sectional design.
Survey period
The survey period was from April 17 to May 15, 2017.
Survey method
The study participants were 2,500 people aged 65 years or older living in City A. Participants were selected from the Basic Resident Register as of April 1, 2017, using multi-stage sampling. Questionnaires were distributed to the participants by mail and responses were collected through direct mailing.
Survey content
To ensure the validity of the questionnaire content, those matching the purpose of this study were carefully selected from previous studies. Data were collected on the following individual attributes: “age”, “gender”, “family structure”, “presence of current work”, “economic life”, “disease under treatment”, “presence of family doctor”, “presence of hobby and recreation activity”, “presence of group affiliation”, and “number of years of residence”.
Questionnaire items on “Social mutual aid in the farm village” were based on those of Inoue et al7). Participants provided answers using a 4-point Likert scale (“strongly agree”, “agree a little”, “don’t agree very much”, and “don’t agree at all”). Responses were collected and analyzed based on a 4-point Likert scale to assess the degree to which participants agreed with statements regarding people or organizations such as “public health nurses in the city”, “local welfare commissioner”, “town association chairperson (residents’ association chairperson)”, “neighborhood association (residents’ association)”, “local elderly care management center”, “social welfare council”, “hospital”, and “family doctors”. This survey was conducted to elucidate the connection between mutual social aid and local social resources in the farm village.
Analytical method
For participant characteristics, the author conducted basic descriptive statistics and calculated basic statistics. For age-specific analysis, the participants were classified into two groups: 65 years or older and less than 75 years (young-old) and 75 years or older (old-old). When the social mutual aid is low, the psychological stress is high factors related to psychological stress were “75 years old or older”8). Associations among variables were examined using the cross test and Mann–Whitney U test. For the closeness of social mutual aid and local social resources in the farm village area, factor analysis (ProMax rotation, maximum likelihood method) was performed to examine whether differences were observed in the factor patterns of young-old and old-old participants. SPSS 24.0 for Windows (IBM Corp., Chicago, IL, USA) was used for statistical processing. Significance levels were set at 5%.
Ethical considerations
This study was approved by the Ethical Review Board of the Faculty of Nursing and Graduate School of Nursing at Iwate Prefectural University (authorization No. 2017-D001, March 7, 2019). Specific measures were taken to ensure the protection of the participants’ human rights. The selection of study collaborators was not arbitrary, and the survey was conducted anonymously. Personal information was handled with confidentiality to ensure that individuals could not be identified based on the results. The participants were informed that the data collected would be used solely for the study’s intended purposes, respecting their privacy, with the study’s objectives also outlined in the description of the survey.
Additionally, the description outlined that statistical processing would prevent individuals and facilities from being identified. The participants were informed they could either agree or disagree to take part in the survey without facing any disadvantages if they declined. Participants were also informed that returning the answer sheet in the envelope provided implied agreement to participate in the survey. Moreover, the researcher was committed to responsibly managing the data obtained on a dedicated personal computer. Questionnaire sheets would be securely disposed of once the study concluded, and the findings were presented at conferences and in an academic journal as a research paper.
Approval for conducting this study involving specific residents was obtained through documentation from the manager of the Public Health Welfare Division of City A, with comprehensive consent from public health nurses. This involved considerations of resident privacy, the use of the Basic Resident Register, and the appropriateness of the questionnaire content.
Social mutual assistance and vital functions
First, social mutual aid in the farm village was defined as a “Mutual help activity including self-assistance of the local residents in the society and organization of farm village”. Second, community development was defined as the “Construction of the better community organization brought by local residents of the farm village”. Third, the closeness of social resources in the local was considered to refer to respondents’ feelings and recognition of people and organizations such as the social resources of “public health nurses in the city”, “local welfare commissioner”, “town association chairperson (residents’ association chairperson)”, “neighborhood association” (residents’ association), “local elderly care management center”, “social welfare council”, “hospital”, and “family doctor”.
Results
Questionnaires were distributed to 2,500 people and 1,226 were collected (collection rate: 49.0%). Responses with incomplete data on items and characteristics needed for the analysis in this study and those with mistakes were excluded from the analysis. Ultimately, 1,011 participants (valid response rate: 82.4%) were included in the formal analysis.
Participant characteristics
As shown in Table 1, 543 (53.7%) participants were categorized as ”young-old” and 468 (46.3%) were “old-old”. Of the participants, 98 (9.8%) reported living in “single elderly households”, while 86.5% responded to the item regarding the number of years they had lived in their residence with “30 years-ancestral home”. In addition, 756 (75.8%) answered affirmatively to the item “Have a family doctor”.
Table 1. Subjects’ attributes (N=1,011).
| Persons | % | Young-old(65 years old–below 75 years old) | Old-old(75 years old or older) | P-value | ||||
|---|---|---|---|---|---|---|---|---|
| Persons | % | Persons | % | |||||
| Age | 326 | 32.2 | 543 | 53.7 | 468 | 46.3 | ||
| Gender | ||||||||
| Male | 430 | 42.5 | 240 | 55.8 | 190 | 44.2 | 0.248 | |
| Female | 576 | 57.0 | 303 | 52.6 | 278 | 48.3 | ||
| Family structure | ||||||||
| Single | 98 | 9.7 | ||||||
| Living together with other family members | 913 | 90.3 | ||||||
| Currently working | 378 | 37.4 | ||||||
| Economical life (no worry about money at all / no worry about money) | 631 | 62.4 | 322 | 51.0 | 309 | 49.0 | 0.001 | ** |
| Have disease under treatment | 786 | 77.7 | 386 | 49.1 | 400 | 50.9 | 0.000 | *** |
| Have family doctor | 756 | 74.8 | 388 | 51.3 | 368 | 48.7 | 0.000 | *** |
| Have hobby or recreation activity | 435 | 43.0 | 266 | 61.1 | 169 | 38.9 | 0.000 | *** |
| Belonging to some group for activity now | 476 | 47.1 | 268 | 56.3 | 208 | 43.7 | 0.119 | |
| Years of residency | ||||||||
| Below 5 years | 19 | 1.9 | 13 | 68.4 | 6 | 31.6 | 0.000 | *** |
| Over 5 years and below 15 years | 19 | 1.9 | 14 | 73.7 | 5 | 26.3 | ||
| Over 10 years and below 15 years | 18 | 1.8 | 13 | 72.2 | 5 | 27.8 | ||
| Over 15 years and below 20 years | 22 | 2.2 | 10 | 45.5 | 12 | 54.5 | ||
| Over 20 years and below 30 years | 56 | 5.5 | 38 | 67.9 | 18 | 32.1 | ||
| Over 30 years and below 40 years | 89 | 8.8 | 67 | 75.3 | 22 | 24.7 | ||
| Over 40 years and below 50 years | 221 | 21.9 | 165 | 74.7 | 56 | 25.3 | ||
| Over 50 years | 198 | 19.6 | 60 | 30.3 | 138 | 69.7 | ||
| Over 60 years, ancestral home | 366 | 36.2 | 163 | 44.5 | 203 | 55.5 | ||
Cross test **P<0.01 ***P<0.001 n.s.: no significant difference at 5% of significance level.
Association between social mutual aid in the farm village and participants’ age
As Table 2 shows, significant differences were observed for the seven items. The scores for individuals aged 65–74 years were consistently low in all cases.
Table 2. Association between social mutual aid farm village and age (N=1,011).
| Items | Cronbach’s α coefficient 0.857 | ||||
|---|---|---|---|---|---|
| Total | Over 65 years and below74 years | Over 75 years | P-value | ||
| n | 1,011 | 543 | 468 | ||
| 1. The residents have ability to coexist with the natural environment | 2.1 ± 0.7 | 2.1 ± 0.7 | 2.1 ± 0.8 | 0.426 | |
| 2. It is a region where people live in accordance with the growth of farm products | 2.1 ± 0.7 | 2.1 ± 0.7 | 2.1 ± 0.8 | 0.413 | |
| 3. Manners and customs from ancient people including the religious service are inherited cherishingly | 2.2 ± 0.8 | 2.2 ± 0.8 | 2.1 ± 0.9 | 0.983 | |
| 4. It is a region where the farmland from ancient people has been inherited cherishingly | 2.2 ± 0.8 | 2.3 ± 0.7 | 2.3 ± 0.8 | 0.022 | * |
| 5. I feel that neighborly relations based on the shared territorial bonding have become weak | 2.2 ± 0.8 | 2.1 ± 0.8 | 2.2 ± 0.8 | 0.143 | |
| 6. I feel that the connection between residents peculiar to the farm village has been weakening | 1.9 ± 0.7 | 1.9 ± 0.7 | 1.9 ± 0.7 | 0.500 | |
| 7. I feel that there is characteristic human relation peculiar to farms | 1.8 ± 0.7 | 1.7 ± 0.7 | 1.8 ± 0.8 | 0.283 | |
| 8. Connection of people peculiar to farms has taken root in the residents’ lives | 1.8 ± 0.7 | 1.7 ± 0.7 | 1.8 ± 0.8 | 0.295 | |
| 9. The entire region is like relative | 1.4 ± 0.8 | 1.3 ± 0.8 | 1.5 ± 0.9 | 0.001 | *** |
| 10. I feel that collapse of the local rules influence the human relation | 1.8 ± 0.7 | 1.8 ± 0.7 | 1.8 ± 0.7 | 0.307 | |
| 11. There are unique rules to stabilize life in the region | 1.4 ± 0.8 | 1.4 ± 0.8 | 1.5 ± 0.8 | 0.030 | * |
| 12. Return gifts for ceremonial occasions in the region are local agricultural products | 0.6 ± 0.8 | 0.5 ± 0.7 | 0.7 ± 0.9 | 0.030 | * |
| 13. It is a region where neighbourhood residents and relatives based on the shared territorial bonding help each other for troubles | 2.0 ± 0.8 | 1.9 ± 0.8 | 2.0 ± 0.8 | 0.005 | ** |
| 14. It is a region where harvested vegetables are actively shared among the residents | 1.9 ± 0.8 | 1.8 ± 0.8 | 1.9 ± 0.8 | 0.035 | * |
| 15. There is mutual help through farming in the region | 1.6 ± 0.8 | 0.5 ± 0.8 | 1.6 ± 0.9 | 0.391 | |
| 16. It is a region where the residents participate in group activities for which products harvested in their farms are utilized | 1.2 ± 0.8 | 1.2 ± 0.8 | 1.2 ± 0.9 | 0.030 | * |
| 17. It is a region where the residents enjoy eating the products they harvest themselves | 1.8 ± 0.9 | 1.8 ± 0.8 | 1.8 ± 0.9 | 0.799 | |
| 18. It is a region where the residents utilize connection with people inside and outside the town well | 1.5 ± 0.8 | 1.5 ± 0.7 | 1.6 ± 0.8 | 0.207 | |
| 19. THe residents serve people except the town residents using their products | 1.4 ± 0.9 | 1.4 ± 0.8 | 1.4 ± 0.9 | 0.785 | |
| 20. The residents work hard to help even people they don’t know using their products and resources | 1.3 ± 0.8 | 1.3 ± 0.7 | 1.4 ± 0.8 | 0.592 | |
Mann–Whitney U test *P<0.05 **P<0.01 ***P<0.001 n.s.: no significant difference at 5% of significance level.
Association between closeness of social resources in the local and participants’ age
As shown in Table 3, significant differences were found for the items of “Family doctor”, followed by “Hospital” and “Town association chairperson (residents’ association chairperson)”.
Table 3 . Association between the closeness of society resources in the local and subject age (N=1,011).
| Items | Cronbach’s α coefficient 0.857 | ||||
|---|---|---|---|---|---|
| Total | Over 65 years and below 74 years | Over 75 years | P-value | ||
| n | 1,011 | 543 | 468 | ||
| 42. I feel the family doctor close | 2.3 ± 0.8 | 2.2 ± 0.8 | 2.5 ± 0.7 | 0.000 | *** |
| 41. I feel the hospital close | 2.2 ± 0.8 | 2.0 ± 0.8 | 2.4 ± 0.8 | 0.000 | *** |
| 37. I feel the town association chairperson (residents’ association chairperson) close | 1.8 ± 0.9 | 1.7 ± 0.9 | 1.8 ± 1.0 | 0.312 | |
| 38. I feel the town association (residents’ association) close | 1.8 ± 0.9 | 1.8 ± 0.9 | 1.8 ± 0.9 | 0.799 | |
| 40. I feel the social welfare council close | 1.6 ± 0.9 | 1.5 ± 0.9 | 1.8 ± 0.9 | 0.000 | *** |
| 35. I feel the public health nurse of the city close | 1.5 ± 0.9 | 1.4 ± 0.8 | 1.7 ± 0.9 | 0.000 | *** |
| 39. I feel the the local elderly care management center close | 1.5 ± 0.9 | 1.4 ± 0.8 | 1.6 ± 0.9 | 0.000 | *** |
| 36. I feel the local welfare commissioner close | 1.4 ± 0.9 | 1.2 ± 0.8 | 1.6 ± 0.8 | 0.000 | *** |
Mann–Whitney U test ***P<0.001 n.s.: no significant difference at 5% of significance level.
Results of the factor analysis for closeness of social mutual aid and resources in the farm village
The overall analysis results are provided in Table 4, while those for the young-old and old-old groups are shown in Tables 5 and 6, respectively. Eigenvalues, scree plots, and cumulative contribution ratios were used to confirm the factors. The “young-old” and “old-old” groups shared a four-factor structure with cumulative contribution ratios exceeding 40%. Cronbach’s α, which is an index measuring internal consistency, was good, with ranges of 0.65–0.90 and 0.69–0.93 for the “young-old” and “old-old” groups, respectively. The items within each factor were analyzed to understand their meaning, and factor names were proposed based on this interpretation. Factor 1 was labeled [Blessings of the farm village and mutual help and assistance unique to the farm village]. Factor 2 was [Closeness of healthcare welfare administration and family doctor in conjunction with own health]. Factor 3 was [Decline of the farm village’s original culture and community accompanied by depopulation]. Factor 4 was [Closeness of the town].
Table 4. Results of the factor analysis for closeness of social mutual aid and social resources in the farm village (N=1,011).
Table 5. Results of the factor analysis for closeness of social mutual aid and social resources in the farm village (young-old) (n=543).
Table 6. Results of the factor analysis for closeness of social mutual aid and social resources in the farm village (old-old) (n=468).
The remaining items for young-old participants were associated with traditions passed down from ancient times, such as [11. There are unique rules to stabilize life in the region] and [12. Return gifts for ceremonial occasions in the region are local agricultural products]. For old-old participants, the items expressed the deep cultural traits of the farm village, such as [3. The manners and customs have been taken from ancient people, including cherished religious practices] and [7. Feeling there are human relationships unique to a farm].
Regarding the correlations among the factors for the young-old group, negative correlations were observed between Factor 4 [Closeness to the town] and each factor. For the old-old group (−0.168 to −0.146), negative correlations were observed between Factor 3 [Decline of the farm village’s original culture and community accompanied with depopulation] and each factor (−0.180 to −0.046).
Discussion
Social mutual aid in farm villages
Factor analysis revealed changing roles concerning self-assistance and mutual aid among older adults in farm villages, emphasizing neighborly relationships. The negative correlation between [Blessings of the farm village and mutual help] and [Decline of the farm village’s culture with depopulation] suggests an association between increased mutual aid and a decline in the unique community of farm villages. Differences in perceptions were noted between young-old and old-old participants with the latter placing greater importance on hospitals and family doctors. Speculating on the increased duties of welfare commissioners after local government mergers could complicate neighborhood relationships. Negative correlations were observed with [Closeness to the town] for young-old participants and [Decline of the farm village’s culture] for old-old participants, indicating nuanced effects on different aspects of the community.
Wakatsuki’s emphasis on the necessity of a healthcare professional network for primary care in rural areas enduring importance of rural medicine9).
Role of public health nurses in community development
Farm villages undergo social transformation which affects local appeal. However, restructuring the mutual aid system has the potential to enhance community life among older adult residents. States that consider community-based integrated care systems are facing a pressing need for local welfare commissioners10,11,12,13).
Public health nurses play pivotal roles in building networks, providing services aligned with local characteristics, and connecting residents with social resources14,15,16,17,18,19). This highlights the necessity for community enhancements that enable older adults, including those with conditions such as dementia, to sustain their preferred way of life. The recognition of nurses’ roles in fostering social capital prioritizes regional effects. Most activities in which public health nurses take part will extend beyond individual aspects.
Limitations
Due to several analytical limitations in this study, further research should be conducted on genuine social conditions, family dynamics, and individual characteristics for a comprehensive evaluation. Although further investigations are required, the insights of this study can contribute to regional health services, including the need for a new performance index or tool to assess the influence of social mutual aid on community development.
Conclusion
This investigation into social mutual aid among older adults individuals in a farm village revealed the differences between younger (young-old) and older (old-old) older adults in their engagement with social mutual aid and local social resources. Notably, the young-old group demonstrated a negative correlation with Factor 4 [Closeness to the town], while the old-old group showed a negative correlation with Factor 3 [Decline of the farm village’s original culture and community accompanied by depopulation]. Establishing a robust data collection and analysis system for prioritizing social mutual aid is crucial for a developing nuanced understanding of and targeting community development initiatives in rural areas.
Conflict of interest
The author declares no conflicts of interest.
Acknowledgments
I gratefully acknowledge the residents of City A for their cooperation throughout this study and thank all those who provided me with advice during the process.
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