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Facilitating nutritional health through the smartphone in rural Japan

LauraHaapio-Kirk7 November 2019

Communal eating in Tosa-cho. Photo by Laura Haapio-Kirk (CC BY).

In September I received the good news that a joint application I made for the newly established Osaka-UCL Partnership Funding was successful. Along with Danny Miller on the UCL side, I teamed up with Dr Yumi Kimura from Osaka University who works on nutrition from a public health perspective in Japan, Myanmar, and the Himalayas. The project also involves Lise Sasaki, who previously studied medical anthropology at UCL. Our proposed collaborative project joins my ongoing anthropological research on smartphone usage among older adults in Japan with Dr Kimura’s public research on nutrition, to develop a mobile health intervention which is sensitive to local usage of mobile phones and attitudes towards health.

The project will take place in my rural fieldsite of Tosa-Cho, a town of roughly 4,000 inhabitants, in Kōchi Prefecture, South West Japan. This rural mountainous area is remote, with the nearest city (Kōchi City) being a 1-hour drive away. Rural towns in Japan are most in need of technological innovation to deal with the growing number of elderly people who are living often alone and in need of care. We know from our ethnographic research that mobile health applications are seldom used by older adults in this town, despite smartphone usage being fairly high. This indicates that there is great potential for digital health interventions but these have to adapt to the way local people are already using their smartphones, rather than encouraging them to download new apps.

Sharing food and conversation. Photo by Lise Sasaki (CC BY).

Over the course of our fieldwork, we have seen this trend across several field sites ranging from Brazil to Ireland: although mHealth initiatives may focus on changing behaviours through the use of native apps built specifically for improving health outcomes, we think making use of the ubiquitous platforms already in common use amongst the target populations could offer significant benefits. We plan to examine the creative ways that older adults are already using common smartphone applications for health and wellbeing, and will explore how these everyday applications could be used for purposes of a nutritional intervention, for example meal tracking using the application Line, or the facilitation of social eating in order to reduce isolation among older adults.

We will present our findings to doctors and health researchers at a symposium in 2020 organised by the UNESCO Chair in Global Health and Education, held at Osaka University by Prof Beverley Yamamoto. We also want to share our findings with the local population of Tosa-cho, so we plan to run a community workshop where we will demonstrate ways for people to use their smartphone to benefit their health and wellbeing. We are hoping that this research and accompanying policy report will reach beyond Kōchi prefecture and will be shared more broadly to advise on digital health policy across Japan. As older adults adopt the smartphone at increasing rates, the potential for mHealth to mitigate some of the health challenges that come with ageing is promising, but initiatives must adapt to already existing behaviours if they are going to have a chance to be sustained.

 

 

‘Ikigai’ – what is your purpose in life? By Laura Haapio-Kirk

LauraHaapio-Kirk25 July 2019

Photo (CC BY) Laura Haapio-Kirk.

I went to meet Wada san* on his land in the heart of the mountains of Tosa-cho, where he grows the plant sasaki, common in Shinto ceremonies and used to decorate altars. He keeps ducks who help him to take care of his rice by eating weeds and harmful insects, and by fertilising the rice crop. He knows the paths and trees in his forest as well as a city person would know the streets and buildings of their neighbourhood. School children often come here to learn about nature and see how we can work with it, such as by making beautiful things out of wood, or healing ourselves with plant remedies. He told us that the plants that are able to grow and thrive here in the mountains, growing up through other vegetation, have the strength to survive and therefore when you eat them you too gain some of that vitality. Along with my research assistant Lise Sasaki and two friends, we spent several hours walking and talking together about happiness and the things in life that give a sense of purpose, in Japanese termed ikigai. While this is quite an abstract term, Wada san was able to explain his ideas through vivid analogies to the landscape that surrounds him.

“What is happiness? Human being’s happiness… I’ve heard that it is health. But after that, its whether or not you find the job you want to devote your life to. I have lived through many jobs and have picked up skills throughout. Now I use those skills to do what I do, my passion. My life story, my life history is written in the mountains, and is remembered by the mountains. Working in an office, once you retire someone else will take on your job. But in this rural area the trees I have planted will grow and remain here, and the trees will be cut down and I will plant them again. It will be a cycle. Not only that cycle, but here – (shows us the rings of a cut tree) you can see how much it has grown, how much it has lived. The trees, even if they are chopped, they will live on as someone else’s house or in another form. It reincarnates as several things. Trees live once in the mountains, giving us oxygen and giving to us our life. And it lives that way. But in its second life, it is transformed into our homes, giving us comfort. We can’t see the oxygen, but it produces it – let’s say it was living in the mountains for 50 years and then it was chopped down and lived as a house for 50 years. Then it has lived for 100 years.”

Wada san explained that trees, like humans, are naturally wild, but that with the right kind of nurture they can find their way in the world. He said that when we are becoming an adult we have to choose our path in life and our role in society – trees are the same. For many people I have spoken to the idea of ikigai is linked to the satisfaction you gain by fulfilling your role in society, especially when you see your positive impact on others. Whether through making delicious bean paste sweets and sharing them with people, or in taking workshops to become a better teacher for your students, people agree that one element of ikigai is about trying your best in serving others.

Everyone has a different definition of ikigai. For some people it refers to dreams and ambitions, such as pursuing a career as an artist, for others it is about doing daily activities which align with one’s interests such as learning English, or for others it is more about the thing in life that you could not live without, such as your children. For some people it is about enjoyment of life, for others it is about the fulfilment of obligations, and some people are in between – a sense of ikigai can come in both difficult and joyous moments and it is more about an underlying feeling of immersion in life.

The English translation of “purpose in life”, it seems, is completely inadequate for understanding the broad range of meanings that ikigai can have in Japan. In England we often talk about life dreams, or working towards goals that we want to achieve. But it seems that people here think about life purpose in a more subtle way, through trying your best day-to-day and being fully present in whatever you are doing. Wada san explained that we must live in the now, rather than waiting for happiness in the future. I think this is an important lesson for us all, especially for people living hectic city lives far removed from the cycles and rhythms of nature. We can often get caught up in our to-do lists and anxieties rather than being fully aligned with our passions and the flow of life.

Human beings are always worried, human being all have anxiety. If your passion wins over, you’re okay. If anxiety takes you over, you can’t take a step. You think life and death are far apart? They’re next to each other. You can die anytime you know? It’s up to you whether you stay anxious or live to the fullest, with passion.” 

Thank you to Wada san for sharing your time, wisdom, and inspiring passion for nature with us.

 

*Wada san is a pseudonym because this man preferred to remain anonymous.

Sharing is caring: communities of abundance in rural Japan

LauraHaapio-Kirk22 October 2018

Harvested corn. Illustration by Laura Haapio-Kirk

Last week I returned from ten days among the wonderful people of my rural fieldsite in Kochi prefecture. The vibrant green rice terraces I had been mesmerised by back in August are now the colour of gold, and in the fields small pyramids of drying rice are beginning to appear. It is harvest season and I was able to experience first hand, as people kept telling me, how Kochi is truly a land of abundance. I was given bags of chestnuts and yuzu lemons, and large Japanese pears (nashi); people here are adamant about sharing the fruits of their labour. The gifting of food binds the community and is, as one woman told me, important for creating a feeling of wealth without money: “Even if we have no money here in Kochi, we have abundance because we can grow so much delicious food and we love to share it.”

Community is sustained in this small rural town through a number of institutional initiatives, such as group activities for elderly residents, or regular workshops in the town hall, for example for new mothers. But it is also through these informal networks of reciprocal giving that community is made. The building and sustaining of community is especially important to people here because Japan’s ageing and shrinking population is felt most acutely in rural areas. It is not rare to come across abandoned schools which have been repurposed as community spaces, and indeed entire empty villages. Yet, I have also come across another quite different picture – young people and families moving into this rural town in search of a slower pace of life and self-sustainability. I have met numerous families who left behind jobs in cities both in Japan and abroad, to start new lives in a place where they feel safe; both protected by a community that looks out for each other, and as a number of people have told me, far enough away from the site of the Fukushima nuclear disaster of 2011 for the food to not be contaminated.

Akaushi – a famous breed of local cow. Illustration by Laura Haapio-Kirk.

This group of relatively recent immigrants, who have mostly arrived within the last eight years, are active on Facebook community groups where they buy and sell clothing, and post about local events. I have been told that local people are less active on Facebook, but perhaps more reliant on one-to-one messaging through Line. However, I have come across local people practicing traditional crafts who share their work on social media. For example, one woodworker in his sixties who uses Instagram to promote his products has customers as far as Tokyo. He told me “It is important for us to be active online because this is how we can reach the rest of Japan and the world, and show the beautiful things that we make here from nature.” Indeed, one of the first people to move to this community eight years ago blogged about her experience and inspired others to follow her move from urban to rural living. Blogs and social media are one way that people in rural Japan can influence a wider perception of the rural from being depopulated and dying, to re-populated and thriving. Social media also provides an opportunity for local people to build and develop their community in new ways. As my bags of fruit demonstrate, they have always had an extraordinary tradition of sharing.

Conducting a health check in rural Japan

LauraHaapio-Kirk22 August 2018

Earlier this month I was invited to help in an annual health check in a rural town in Kochi prefecture. I had wanted to find a rural comparative site to my main fieldsite of Kyoto, so when Dr Yumi Kimura, a researcher at Osaka University, invited me to participate in the health check, this seemed like the perfect opportunity to establish myself in a rural community. I arrived in Kikuyama* on a Sunday afternoon along with my research assistant, Lise Sasaki, and about 50 other researchers, students, doctors, and dentists. The five-hour train and bus journey from Kyoto ran alongside sparkling clear turquoise rivers winding their way through lush mountains.

We were first briefly taken to a scenic spot to view rice terracing; breath-taking luminous green tumbling down the mountainside. But that was the limit of our sightseeing; we soon got down to business. We were expecting to welcome about 300 people to the health check over the next five days so we spent that Sunday afternoon preparing. The health check was to take place in a large hall adjacent to the town’s health clinic. We set up distinct areas for different kinds of medicine and tests, including areas for dentists, cardiologists, gynaecologists, mobility and dexterity tests, dementia tests, driving tests, blood tests, and a space for general practitioners to give consultations at the end of the visit. The area where Lise and I were stationed featured a machine called InBody which we used to measure body fat and muscle percentage.

The machine works by running a small electric current via electrodes placed on the fingers and ankles. Over the course of the week, while we attached and removed electrodes, we had a chance to chat with people about their health. This was a great opportunity to meet a large number of people in a short space of time and to establish myself as a known person to this community. Many were very surprised to see a foreigner, and some even asked to touch my hair, telling me it was the first time they had seen someone with fair hair and skin up close. Given the hectic nature of the health check we were only able to have long conversations with a few people, most were limited to about five to ten minutes. However, we managed to get a sense of the topics that were most insistent and frequently occurring in relation to health: work, food, luck, and community. Identification of these key topics will direct my conversations that are scheduled during my return trip in October, when I am planning to conduct more in-depth interviews and also do filming. Without participating in the health check I feel it would have taken much longer to build up trust with this rural community, especially as a foreigner, but now we have many invitations to visit people in their homes.

I will save a longer discussion of the above mentioned topics for a blog post after my second visit to the site, but for now I will briefly explain why the topic of work appears so pertinent to understanding how health is conceived in this community. Most people we met were rice farmers or foresters, often still working well into their 80s. The foresters had extremely big hands which were often missing fingers, and the rice farmers were deeply tanned from spending their days in the fields. This is hard work which leaves its mark on the body, yet when asked what is the secret to staying healthy and energetic (genki) in old age nearly everyone said that daily work is key. Men and women appeared to be equally committed to farming, while all of the foresters were male. For some farming had been a life-long career, and for others they had taken it up after retiring from other jobs. While the physical nature of strenuous work appears to benefit the physical health of these strong elderly people, I am particularly fascinated by how the sociality of work affects people’s emotional and mental health. Farming requires communication, not only with suppliers and buyers, but also with fellow farmers about how to cooperate and to manage seasonal fluctuations. People also mentioned that they socialise with people who do the same work: a rice farmer will go and have sake now and then with fellow rice farmers in their association. The significance of work for health in later life appears to be about more than staying active or having an income, it seems to be central to maintaining a sense of belonging within a community. I look forward to further exploring this topic, along with the others, in the months to come.

 

Text and Illustrations by Laura Haapio-Kirk

*A pseudonym is used in order to protect privacy.

Work, stress, and health in Japan

LauraHaapio-Kirk4 July 2018

Photo (CC BY) Laura Haapio-Kirk

“Because of my job it is not easy to feel Im living a healthy life. If you have a stressful life or stressful job it is a cause of ill-health. Work gives you stress but you need work to be healthy.”

This quote is from Tomoko san, a teacher who is near the age of retirement but is not considering retiring any time soon. She works six days per week and lives alone, her adult daughter living in another city. We met in the botanical garden and, after feeding turtles, we chatted overlooking a small lake and ate rice crackers that she had brought. We talked about health and in particular its relationship to stress which has surfaced as the most commonly cited source of ill-health in my conversations with people so far. She works hard and acknowledges that work stress, particularly social stress from colleagues and parents of students, causes ill-health. But at the same time she recognises that routine and purposeful work keeps her healthy. Her quote above is interesting because it captures this idea of work as both the main cause and prevention of ill-health, expressed in different ways by all of my informants. The routine and stimulation provided by work, especially of interacting with younger colleagues, has been cited as a way that people feel like they might retain their youth and stay healthy.

Diminished mental health, widely recognised by my informants under the umbrella term “stress”, does not appear to be as much of a priority to address as bodily health and fitness. Work and social relations are simply accepted as stressful because of a deference to hierarchical structures within social life. Colleagues often may not leave work until after their boss and then, if they are required to go drinking together, they also cannot leave the bar until their boss wants to. If a boss is insensitive to the exhaustion of their colleagues, this is known as power hara or power harassment. This kind of intense pressure from social bonds is often accepted as a source of stress and ill-health which people can do little about. As one informant told me with a sense of resignation “we (Japanese) have a lot of stress in daily life”. Unsurprisingly the mindfulness trend seen in Europe is also popular in Japan. However one of my informants said that mindfulness is just trendy and that people don’t really practice such activities in their daily lives. Japanese cultural activities such as tea ceremony and flower arranging (ikebana) are also supposed to be a form of paying attention and mindfulness, but as someone told me “ordinary people want to learn (such things) because its cool. For us, the mind is not so important, lifestyle is much more important. Mental health is not visible, whereas your body is, so people easily forget to take care of their mental health. How we look is very important.” One woman in her 40s confirmed these sentiments when she told me that the invisibility of mental health means that people often ignore warning signs and then reach burn-out stage. This is what happened to her while working as a designer, a job which often required 14-hour days. She subsequently quit the profession entirely and is now working as an administrator for a medium-sized company, where she feels less pressure to work excessively and therefore her health has returned.

Another person I have been getting to know is Hiroshi san, a 66-year-old nurse who also works 6 days per week. He tried retirement for 3 months but found that he wasn’t writing the novel he had planned to write, and instead felt anxious that others were doing more than him and being more productive, so he returned to work. For him, his peers are rivals who he feels in direct competition with, and retirement means dropping out of the race. Other people have told me that they don’t want to retire because it’s not healthy, they will just end up watching tv all day long, which they feel will shorten their lives. Work and “ikigai”, or purpose in life, are so bound up with health in Japan, yet in every conversation I’ve had people cite work as their main cause of stress and stress as their main cause of ill-health. This is a paradox I wish to further explore in the coming months.

Author: Laura Haapio-Kirk

Note: all names used are pseudonyms.

Infrastructures of Care

LauraHaapio-Kirk19 April 2018

Photo (CC BY) Laura Haapio-Kirk

Someone recently told me about how he encourages his 86-year-old mother, whom he lives with, to use her home blood pressure monitor every day and record her readings in a notebook. He said that doctors had prescribed her medication to lower her blood pressure, which she did not like to take. His solution was to turn to traditional Japanese medicine which he explained is tailored to the individual’s body, rather than western medicine which relies on a universal concept of the body. He was able to track the success of this approach through the home monitoring kit, and now her blood pressure is back to normal. This story reveals how infrastructures of care are made up of various integrated systems – that blockages in the form of non-adherence may reveal alternative routes by which people navigate care and self-care.

I am part of a reading group at Osaka University hosted by Gergely Mohacsi and Atsuro Morita. A few weeks ago we discussed Morita’s recent co-edited volume called ‘Infrastructure and Social Complexity’ (Harvey, Bruun, Morita 2017). He explained that a recent focus on infrastructure in social sciences, indeed an ‘infrastrucutural turn’ in anthropology, is a result of infrastructures becoming increasingly precarious and therefore more visible. Ageing infrastructures are becoming more and more tangible as we bump up against cracks in roads and other markers of decay. Infrastructures are systems that should enable things to flow, whether that’s water, electricity, goods, or people. But what happens when people are disconnected from infrastructures, or for whatever reason the flow is blocked?

Photo (CC BY) Laura Haapio-Kirk

I began to think about how smartphones are integral to navigating many of the infrastructures that enmesh us, for example through maps that visually place you within an infrastructure of roads, or health apps that extend the infrastructure of a national health service towards more individualised care. However, as digital technology becomes more integral to health services will people with limited access (through lack of digital literacy, or affordability for example) face increased marginalisation from infrastructures of care? And how are health professionals to identify blockages in the flow of care before it’s too late for individual patients? In such cases where care is not received, it is not only the infrastructure which is revealed to be vulnerable, but individuals themselves.

A couple of days after the seminar I happened to read a newly published article titled ‘Thinking with care infrastructures: people, devices and the home in home blood pressure monitoring’ (Weiner and Will 2018) in which the authors use the concept of care infrastructure to look at the variety of people, things and spaces involved in self-monitoring using a blood pressure device. Their work reveals self-monitoring as a socio-material arrangement that expresses care for self and for others, as opposed to focusing only on the individual and the device: “Specifically, our analysis has drawn attention to the range of local actors and work involved in the practice of self-monitoring, even in the case of consumer technologies. Through this attention to work, monitoring may also come to be seen as involving not just data, but also care amongst kin, family and colleagues.” My intention for my research was always to look at smartphones as situated within wider practices and things including other technologies and people, but thinking specifically in terms of infrastructure expands my scope and gives rise to questions about how multi-layered flows are connected (or not), ranging from state level, to family based care.

References

Harvey, P., Jensen, C. B.Morita, A. (2017). Infrastructure and Social Complexity. Routledge

Weiner, K. and Will, C (2018) ‘Thinking with care infrastructures: people, devices and the home in home blood pressure monitoring’ in Sociology of Health and Illness 40: 270–282. doi:10.1111/1467-9566.12590.

Individualised Japan

LauraHaapio-Kirk22 February 2018

(CC By) Laura Haapio-Kirk

Yesterday I met a woman who told me about her grandmother who lived until the age of 99 years and 11 months. She told me how she lived alone in the countryside yet was busy every day up until the end of her life. In her later years she took it upon herself to care for the mountain behind her house, focusing especially on ridding it of weeds. Her granddaughter claimed this daily (and apparently endless) work was one of the main reasons why she maintained her health up until the end. Such stories have been told repeatedly to me in the three weeks since arriving in Japan. Stories of elderly people maintaining their health by cultivating vegetables, teaching traditional arts, or indeed weeding mountains, abound.

(CC By) Laura Haapio-Kirk

From the conversations I have had, there appears to be a social expectation for an individual to maintain an active life for as long as possible and to continue to contribute to society in old age. This can also involve minimising the appearance of frailty and dependence. Another woman told me of how her grandmother, who also lives alone, makes use of a local health facility which picks her up in a minibus twice a week. However, she does not let the minibus collect her from outside her house, preferring to walk around the block so that her dependence on institutional support will not be visible to the neighbours. For this elderly woman, the fact that she lives alone and not with her family gives rise to sense of shame. She continually puts pressure on her children and grandchildren, asking when they will move closer to take care of her.

What is fascinating to me is the tension between an individual’s responsibility for self-care and the social motivations for maintaining one’s health. As Japan undergoes a shift towards a more individualised society (Allison, 2013), consequences such as loneliness and isolation are felt particularly by the elderly, especially if they are used to living in traditional multigenerational households (known as ie). However, my project focuses on the middle-aged who are caught in the middle of these tensions. They both desire the privacy and independence of living apart from parents, while wanting to fulfil their sense of filial piety. The couple with whom I am staying are both in their 60s and close to retirement. Their house is attached to that of the husband’s parents who are in their 90s and mostly independent. The elderly parents shop and cook for themselves and I have witnessed only rare interaction between the two households. The main mode of communication is an interphone system which buzzes sometimes in the evening, for example when the grandmother wants to share gifts of food she has received from the temple, or simply to let her son know that she is going to bed. While the elderly parents do not own a telephone, the interphone allows them to maintain a separation while facilitating daily communication. As monitoring and smart home technology becomes more commonplace, it will be interesting to see if this technology accelerates the trend towards an individualised society by facilitating care at a distance.

 

References

Allison, A. (2013) Precarious Japan. Duke University Press

 

The Burden of Caring in Japan

LauraHaapio-Kirk5 January 2018

Image (c) Laura Haapio-Kirk

A recent news story titled Dying at home rather than in hospital, elderly Japanese “go to the afterlife quietly caught my eye with its suggestion of a preference for home deaths in Japan. The location of palliative care and the relationship of a dying person to their caregivers, whether they are relatives or professionals, can reveal a great deal about an individual’s social world, as demonstrated in Miller’s recent book The Comfort of People. Upon closer inspection the article’s title proved to be misleading; Japanese cultural beliefs surrounding death and the avoidance of burdening others (Long, 2012) indicate that the situation is more complicated.

The article claims that the current shortage of hospital beds combined with the expense of professional medical care means that for many people the choice to die in hospital is taken away from them. One reason why hospital care may be preferred over family care is that over half of Japanese carers are pensioners themselves (Hurst, 2017). The Japanese term rou-rou kaigo describes the common practice of care between the elderly. Our ASSA project focuses on people between the ages of 45-70 who may be both experiencing embodied reminders of ageing, while simultaneously caring for their ageing relatives. We will study how care is mediated through technology, specifically through the smartphone, such as by maintaining self-care through mHealth apps or caring for others through connected devices.

In Japan, not wanting to be a burden in death can be understood as a final act of care towards one’s family. I am wondering whether this may help to explain people’s interest in new technologies such as smartphones. Perhaps older people are hoping that technology will give them a means to look after themselves more effectively and so be less dependent upon their families. Or perhaps, as Long’s article suggests, some people resist such technologies precisely in order to preserve what they consider to be traditional Japanese family values. By conducting my research in Japan where life expectancy is the longest in the world, I hope to deepen our understanding of the possibilities afforded by a prolonged mid-life and explore how family relationships and networks of care are affected by the simultaneous rise of the smartphone.

– Laura Haapio-Kirk

 

References

Long, S.O. J. 2012. ‘Bodies, Technologies, and Aging in Japan: Thinking About Old People and Their Silver Products’ in Cross Cultural Gerontology (2012) 27: 119. https://doi.org/10.1007/s10823-012-9164-3

Hurst D. 2017. ‘More than half of Japanese carers are pensioners’ in The Times June 28 2017. Retrived 23..11.2017 (https://www.thetimes.co.uk/article/half-of-japanese-carers-are-pensioners-themselves-n2v3glbkz)

Dying at home rather than in hospital, elderly Japanese ‘go to the afterlife quietly’ (November 20, 2017) Retrieved from https://www.reuters.com/article/us-japan-homedying/dying-at-home-rather-than-in-hospital-elderly-japanese-go-to-the-afterlife-quietly-idUSKBN1DK2LB