Visual abstract

Introduction

With the increasing desire for a comprehensive health approach, there is a growing interest in integrative medicine (IM). Traditional, complementary, and alternative medicine (TCAM) may contribute to preventing and treating behavior- and lifestyle-related infectious and chronic conditions/diseases [1–3].

Many IM practices focus on lifestyle changes, such as healthy eating, exercise, stress management, and mind-body techniques, to promote health and prevent chronic conditions/diseases [4,5]. These initiatives often involve a multidisciplinary team of healthcare providers, including internal medicine physicians, naturopathic doctors, nutritionists, and other practitioners who collaborate to provide personalized care tailored to individual needs [6].

The “2014–2023 Traditional Medicine Strategy” by the World Health Organization underscores the growing integration of TCAM into global healthcare, reflecting varying degrees of acceptance across countries [7]. This strategy highlights the role of IM in meeting healthcare needs amid changing condition/disease patterns and increasing health awareness [8]. With rising consumer expectations, and the challenges of chronic condition/disease management and aging populations, TCAM is emerging as a vital, accessible, and affordable healthcare option [8]. Referring to the definition by the National Institutes of Health of the United States of America [6], complementary and alternative medicine (CAM) and TCAM were defined as being part of IM.

In Japan, there is a changing population structure, including an overall population decrease with declining birth rate and an increasing elderly population, and the development of a less homogeneous society, are impacting the condition/disease landscape, and affecting the healthcare system [9]. Conventional healthcare systems alone do not appear to be able to meet the diverse medical and social needs that are required, and there is an increasing demand for integrated healthcare systems. To meet this demand on the healthcare systems, the Society for Integrative Medicine Japan has proposed a “medical model,” and a “social model” based on IM practice whereby TCAM is combined with modern medicine in a coordinated manner [10]. The “medical model” is positioned to respond to a patient’s illness through a multidisciplinary team system focusing on the patient, while the “social model” aims to improve the quality of life (QOL) of residents through multigenerational collaboration in the local community. As a “social model,” the IM program aims to prevent the spread of disease, promote healthy habits, and improve the health of all people, and aims to establish and sustain healthy living spaces that prioritize the overall well-being of the entire community [11].

Governments play an important role in health promotion and protection, with local government well-placed to implement policies due to their community insights and capacity to meet local needs. IM interventions are important for condition/disease prevention and overall health improvement in these health programs. However, the effectiveness of these programs needs nationwide evaluation to give clarity.

This study was conducted in Japan in 2018 [before local government health programs were cancelled because of the coronavirus disease 2019 (COVID-19) pandemic] to investigate the use of IM by local government in Japan and its safety and effectiveness as a “social model.”

Materials and Methods

1. Search for IM health-promotion programs in Japanese local government

The National Diet Library of Japan updates a website, Web Archive Project (WARP) [12] 4 times per year which acts as a repository for the websites of all 1,944 Japanese local governments. The name of the city, town, or village was selected on the WARP website to access the individual web pages of Japanese local governments in 2018. The IM programs were extracted, including IM vocabulary, from the 4 entries for each local government which were archived on WAPR in 2018. The types of IM, the qualifications of the providers, the number of sessions, and the purpose of the programs were retrieved.

2. Analysis of IM programs

The IM programs extracted from the WARP website were analyzed according to the classification of IM in the “Information Site for Evidence-Based Japanese Integrative Medicine” (Table 1 [13]).

3. Data analysis

Data were analyzed using Microsoft Excel (Microsoft 365 Apps): the mean (arithmetic mean) and percentage of the parameters were calculated.

Results

1. IM programs implemented by local government

A total of 1,739 IM programs were implemented by 537 local governments (27.6% were adopted across every Japanese local government; Table 2). The types and numbers of IM programs implemented were Yoga 1,242 (71.4% of all IM programs implemented), Qigong (Tai Chi) 211 (12.1%), Aromatherapy 145 (8.3%), Massage 47 (2.7%), Music therapy 32 (1.8%), and all others combined 40 (3.6%). In addition, the following IM programs were implemented (0.1%), although in smaller percentages: Medicinal diet, Kampo medicine, Chiropractic, Moxibustion, Acupuncture, Diet therapy, Dietary education, Spa therapy, Ayurvedic medicine, Forest therapy, Supplements, and Health food.

2. Implementation sessions per program

The number of sessions for Yoga, Qigong, Aromatherapy, and other programs was analyzed (Table 3). Most programs had 11–20 sessions, with Qigong being the most repeated activity (25.8% for Qigong versus 18.6% for Yoga). Aromatherapy programs were usually held as single sessions (49%), while 30.9% of Yoga sessions, and 45.1% of Qigong programs were repeated 10 or more. The average number of sessions in a program was 6 for Yoga, 9 for Qigong, and 2 for Aromatherapy, and the weighted average values for Yoga, Qigong, and Aromatherapy were 8.0, 12.3, and 4.1, respectively. Additionally, there were several programs for which the number of sessions could not be identified.

3. National qualifications for providers of IM programs

No official Japanese national licenses exist for IM providers, except for those providing Acupuncture, Moxibustion, Judo, and Anma-Massage. Among the IM programs investigated, there were 16 national medical-related license holders (including 5 registered dietitians, 3 pharmacists, and 2 midwives) representing only 0.9% of the total number of providers (16 of the total 1,739; Table 4). Data for other programs were not available.

4. Purpose of the treatment regarding condition/disease prevention and health promotion

The purpose of condition/disease prevention or health promotion was mentioned in 14% of Yoga programs (169 out of 1,242 cases), 13% of Qigong programs (28 out of 211), and 5% of Aromatherapy programs (8 out of 145 cases) but the purpose was not described with scientific basis (safety and effectiveness). Health-promotion program slogans were found among these archived websites (Table 5), but the impact of these slogans and the results of the IM programs were not posted (with the exception of a few).

Discussion

The implementation status of IM programs, in 2018, by Japanese local government was assessed for the first time from the viewpoint of the “social model.” Japan’s national plan primarily focuses on extending healthy life expectancy [14], and integrated health promotion is implemented in Japan to improve QOL. Evidence supporting the long-term benefits of state intervention is limited [15].

Amidst the COVID-19 pandemic in 2020, a significant portion of Japan’s population, particularly the elderly, faced heightened risks of morbidity and mortality. Group exercise activities for the elderly in Japan were suspended [16].

It is essential to better understand the progress of implementing health promotion programs, including IM practices like Yoga and Aromatherapy. The role of IM in Japan’s healthcare system has been a topic of ongoing discussion with the aim to advance IM to enhance life expectancy. There were no official Japanese national licenses for IM health promotion programs, except for the those providing Acupuncture, Moxibustion, Judo, and Anma-Massage (Table 4). This study determined that Yoga (71.4%) was the most widely offered IM program by Japanese local government, followed by Aromatherapy (8.3%) and Qigong (12.1%). However, only a limited number of program providers possessed national qualifications, and detailed information about the program purpose. Outcomes were provided for only a few programs. Even though the World Health Organization Traditional Medicine strategy emphasizes the integration of TCAM health practices, some countries, for example Spain, has a “Plan for the Protection of Health against Pseudo therapies,” introduced by the Ministry of Health and Science which identified 73 practices as pseudo therapies including Acupuncture and Ayurveda [17]. A speaker on economics and policy at the Conference in Washington on Integrated Traditional Chinese and Western Medicine and Public Health in 2009, emphasized that the body’s natural state is one of health and public policy should support this inherent process of promoting health [18]. He highlighted the important roles of healthcare professionals, educators, physical trainers, counsellors, and others in safeguarding physical and mental well-being [18]. It is important for healthcare professionals to be involved in health promotion programs, and medical doctors should supervise these programs, especially if the Japanese central government wants them to lead IM. As for Qigong, no Qigong program providers had any national medical-related qualifications. Aromatherapy is a popular IM, but despite its popularity, health professionals need to gain more familiarity with it.

This study shows that no municipality has announced the results of the IM or health promotion programs (with the exception of a few). Effective health promotion initiatives require collaboration between government and researchers. The programs should be tailored to each country’s unique healthcare landscape after identifying the root causes of implementation challenges [19].

Central supervision and local action allow interventions and programs to be tailored to local needs and resources. However, the quality of every local plan cannot be guaranteed. Although the central government rewards high-quality practice, there is no regulation, incentive structure, or support to ensure a minimum level of quality [20]. Therefore, it is important to ensure the quality of programs to promote local government-funded IM health programs as a “social model” of IM. The IM projects for condition/disease prevention and health promotion should be promoted with the local government as the main body to enhance residents’ QOL.

Furthermore, there is a problem in that the implementation of various CAM therapies are not based on sufficient evidence [21]. Japan has a decentralized public health system, but local government prioritize experts rather than community opinions regarding on public health programs [21]. Therefore, in the related projects of integrative medical health promotion, experts are essential in guiding the health promotion plans using IM.

In addition, the Ministry of Health, Labour, and Welfare of Japan, require IM to be led by physicians [22]. This might affect the attitude and approach of local government. The findings of this study highlight the lack of certified expertise for each IM program and this poses significant challenge. If the central government of Japan require that medical professionals should lead IM initiatives, it follows that these professionals should oversee the plans developed by local government.

Health promotion programs include individual and community action, healthcare system strengthening, and multisectoral partnerships. These programs target specific health conditions and can be implemented in various settings such as schools, hospitals, workplaces, and residential complexes [23]. Under the Health Promotion Law (Kenko Zoshin Hou), the government, prefectures, municipalities, and medical institutions are expected to collaborate to provide health education to enhance healthcare literacy in Japan [20]. However, inadequate infrastructure, lack of information, and training are the main difficulties in the implementation of health promotion programs [24]. Therefore, prioritizing infrastructure, information dissemination, and education training is necessary for effective planning.

The websites for IM programs often do not explicitly mention “disease prevention/health promotion,” and many programs have ambiguous objectives. IM practitioners must receive proper training in evidence-based health promotion counselling to address the risk factors for individuals using IM. During these consultations health promotion messages can be aligned with the patient’s primary healthcare provider [25]. Even when the project outlines the aim of “preventing illness and promoting health,” there is no evident rationale for it.

The lack of uniformity in medical system policies has resulted in a lack of understanding and promotion of integrated medical care by healthcare professionals. It is crucial for the medical system to recognize the importance of integrated medical care, and for healthcare professionals to be trained in this area to recommend and implement such health promotion plans effectively. Collaboration between integrated medical care and the medical system is essential for advancing healthcare.

There is a close relationship between IM and health promotion [26], and this underscores the importance of prevention, health promotion, and empowering patients [27]. Research in Taiwan [28], and South Korea [29] indicate that the local government of these countries incorporate IM into health promotion policies, consistent with the findings of this current study. It is vital to promote health measures, although different communities face unique health challenges [30–32]. However, there is still a need for more knowledge and a need for comprehensive planning. To address this, IM health promotion planning in the future could prioritize moderators, implement solutions tailored to actual needs, address identified challenges, and respond to urgent needs reflected in healthcare systems across different nations.

The study was carried out using data from 2018. The local Japanese government has been actively engaged in infectious disease prevention following the COVID-19 pandemic. However, evaluating the effectiveness of their information management programs has proven to be challenging due to the necessity of finding published results on various local government websites. Since the COVID-19 pandemic may have shifted people’s perspectives, public and government perceptions will likely change in the post-COVID-19 era.

Conclusion

Japanese local government offer IM programs, but typically implemented by unqualified providers as observed in other countries. Proper training and certification for healthcare personnel and the development of suitable programs for local communities’ needs are crucial in the expansion of health promotion initiatives using IM.

Article information

Author Contributions

Conceptualization: KY, YM, and IA. Methodology: IA. Validation: HC and IA. Formal analysis: HC, MM, and YH. Investigation: MM and YH. Data curation: HC, MM, and YH. Writing - Original Draft: HC. Writing - Review & Editing: FC, KY, YM, IA. Visualization: HC. Supervision: FC. Project administration: IA.

Conflicts of Interest

Yoshiharu Motoo received honoraria from Tsumura & Co. The other authors have no conflicts of interest to declare.

Funding

Funding for this research was supported by the Japan Agency for Medical Research and Development (grant no.: 19lk0310065h0001).

Ethical Statement

This research did not involve any human or animal experi-ments.

Data Availability

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