Health education interventions across Thailand, the Philippines, and Japan: A multisite comparison in varying socio-environmental and policy contexts

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Standardized programs, based on a shared health education framework, were delivered for 6 to 12 months in Sampran (Thailand), Cebu (Philippines), Matsumoto City, and Minowa Town (Japan), targeting older adults and working-age populations. A total of 481 participants were assessed using anthropometric measurements, blood pressure, physical fitness tests (e.g., grip strength, sit-ups, balance), and cognitive function tests (reaction time and error rate via a go/no-go task device developed at Shinshu University). Physical activity was measured using pedometers to track daily steps. Significant improvements were observed in weight, BMI, muscular strength, balance, and executive function across several sites. In Minowa Town, where participants averaged 73 years in age, the average daily step count was 8,701. This finding suggests that sustained behavioral change may be linked not merely to step targets, but to internalized understanding of the health benefits of physical activity. While more than 7,000 steps per day is generally considered beneficial, our results indicate that age, motivation, and social context may moderate these outcomes. These findings underscore the importance of age- and context-appropriate interventions that integrate both physical and cognitive health components. This study also highlights the value of culturally adaptable health education strategies when addressing diverse populations across national boundaries. Figures Figure 1 Figure 2 1. Introduction Globally, life expectancy increased from 66.8 years in 2000 to 73.4 years in 2019, while healthy life expectancy (HALE) rose from 58.3 to 63.7 years. However, this gain in HALE lagged behind the overall increase in life expectancy, mainly due to declining mortality rather than reductions in years lived with disability. The COVID-19 pandemic reversed these gains, lowering life expectancy and HALE to 71.4 and 61.9 years, respectively, in 2021—levels comparable to those in 2012 [ 1 ]. These trends highlight the urgent need to enhance health standards and extend HALE globally [ 2 ]. Improving population health has major socioeconomic implications. In Japan, for example, absenteeism, presenteeism (working while sick), and early retirement due to poor health contribute to a 7% loss in GDP, amounting to $ 370 billion—nearly 38% of the national budget [ 3 ]. Enhancing public health not only improves quality of life but can also stimulate economic growth. Studies suggest that individuals who participate in comprehensive health education programs are less likely to adopt harmful behaviors such as excessive alcohol intake, smoking, or drug use [ 4 ]. Occupational safety and health (OSH) is defined as the anticipation, recognition, evaluation, and control of workplace hazards that may affect worker well-being and surrounding communities [ 5 ]. The International Labour Organization recommends workplace health promotion programs to reduce illness- and accident-related costs [ 6 ]. In 2019, HALE was estimated at approximately 63 years in Thailand, 61 years in the Philippines, and 72 years in Japan. Since 1988, we have implemented dementia prevention programs as part of community-based health education in five regions of Nagano Prefecture, Japan. These initiatives promoted empathy and cooperation, using a social capital-oriented framework [ 7 – 11 ]. Since 2013, our program has been adapted for communities near Mahidol University (Thailand), Udayana University (Indonesia), and Southwestern University (Philippines). We adopted the PDCA (Plan–Do–Check–Act) cycle for quality assurance and obtained ISO 9001 certification in 2014 (self-declaration since 2021) [ 12 – 18 ]. The primary aim of this study is to evaluate the effects of standardized health education programs on physical and cognitive health among older adults and working-age individuals across four diverse regions: Sampran (Thailand), Cebu (Philippines), Matsumoto City, and Minowa Town (Japan). 2. Method 2-1. General methods This quasi-experimental pre-post study was conducted as a health education intervention from March 2017 to February 2018 across four sites: Sampran (Thailand), Cebu (Philippines), Matsumoto City, and Minowa Town (Japan). Participants were recruited through public announcements and information sessions organized in cooperation with local governments and universities. Only individuals who provided written informed consent were included. Random sampling was not feasible due to logistical constraints, so convenience sampling was used. Although the sample size was not statistically predetermined, efforts were made to ensure sufficient representation from each site, and baseline characteristics were collected to confirm demographic comparability where possible. Descriptive statistics and post-hoc power analyses were employed to assess the adequacy of sample sizes for detecting within-group changes. The duration and participant characteristics at each site were as follows: ・Sampran, Thailand (January–September 2017): 13 participants (mean age: 39.8 ± 7.3 years; 4 men [34.3 ± 4.3 years], 9 women [42.3 ± 7.0 years]) ・Cebu, Philippines (March 2017–February 2018): 43 participants (mean age: 35.6 ± 7.0 years; 22 men [36.4 ± 7.0 years], 21 women [34.8 ± 7.2 years]) ・Matsumoto City, Japan (May 2017–February 2018): 66 participants (mean age: 67.3 ± 6.7 years; 14 men [70.7 ± 5.9 years], 52 women [66.3 ± 6.6 years]) ・Minowa Town, Japan (May–December 2017): 48 participants (mean age: 72.6 ± 4.0 years; 15 men [73.5 ± 4.6 years], 33 women [72.3 ± 3.8 years]) Each program followed a standardized structure consisting of baseline and post-program measurements, physical exercise demonstrations, and health education lectures. The overall intervention design is outlined in **Fig. 1**, and demographic and timeline information is shown in Tables 1 and 2. [Insert Fig. 1 here] 2.2 Ethical Considerations Participation in this study was entirely voluntary, and individuals could withdraw at any time without any penalty. Prior to participation, all subjects received a detailed explanation of the study objectives, procedures, and potential risks. Written informed consent was obtained from each participant, and all data were treated confidentially in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the ethics committees of Mahidol University in Thailand (No. 01-58-10), Chong Hua Hospital in Cebu City, Philippines (IRB1389-09), and Shinshu University in Japan (Approval No. 180; April 14, 2017). All procedures were conducted in accordance with institutional and international ethical standards. Human Ethics and Consent to Participate declarations: Written informed consent was obtained from all participants prior to data collection. The study was approved by the following ethics committees: - Mahidol University, Thailand (Approval No. 01-58-10) - Chong Hua Hospital, Philippines (Approval No. IRB1389-09) - Shinshu University, Japan (Approval No. 180; April 14, 2017) 2.3 Pedometer-Based Physical Activity Measurement Daily physical activity was monitored using a pedometer (JP800, Acos Co., Ltd., Japan) throughout the intervention period. Step counts were categorized based on metabolic equivalents (METs): “walking” steps (fewer than 4 METs) and “exercise” steps (equal to or greater than 4 METs), where 1 MET represents energy expenditure while sitting at rest. 2.4 Anthropometry, Blood Chemistry, and Blood Pressure Anthropometric measurements, including body weight and BMI, were recorded using a body composition monitor (HBF-359, Omron Healthcare Co., Ltd., Japan). Blood chemistry parameters were assessed in the fasting state (>10 hours). Systolic and diastolic blood pressure were measured using a mercury sphygmomanometer (Kenzumedico 0601B001, Japan) after participants had been seated at rest for 15 minutes in a temperature-controlled room (25°C, 50% relative humidity). 2.5 Physical Fitness Assessments Physical fitness was assessed using the standardized “New Physical Fitness Test” for older adults, developed by the Japanese Ministry of Education, Culture, Sports, Science and Technology [19]. Six performance tests were conducted before and after the program: ・Hand grip strength (T.K.K.5001, Grip-A; muscle strength) ・Sit-ups (muscle endurance) ・Sit-and-reach test (Toei Light, T2421; flexibility) ・Eyes-open, single-leg stance (balance ability) ・10-meter obstacle walk (walking ability) ・Six-minute walk test (aerobic endurance) These assessments were used collectively to evaluate changes in overall physical fitness. 2.6 Cognitive Function Test: Go/No-Go Task Cognitive inhibitory control was evaluated using a go/no-go task device developed by the Faculty of Engineering at Shinshu University [11, 17, 20]. The test comprised three stages: 1. Formation stage (5 trials): Squeeze a rubber ball in response to a red light. 2. Differentiation stage (20 trials): Respond to red light and withhold response to yellow. 3. Reverse differentiation stage (20 trials): Respond to yellow light and withhold response to red. In the latter two stages, red and yellow lights were each presented 10 times at random. Stimuli were presented at intervals of 2.5 to 3.5 seconds, randomly varied to prevent anticipatory responses. Each participant completed the task in approximately 3–4 minutes, including brief instructions and setup time. The test was conducted in a quiet room maintained at approximately 25 °C and 50% relative humidity, under standardized lighting conditions. Participants were seated at a standard desk approximately 60–70 cm high, and received standardized verbal instructions prior to the test. In this study, a "missing" (i.e., omission) was defined as a failure to respond to a Go stimulus, and a "mistake" (i.e., commission error) as an inappropriate response to a No-Go stimulus. The total number of errors was calculated as the sum of omissions and commission errors. 2.7 Statistical Analysis One-way analysis of variance (ANOVA) was used to compare step counts among the four regional groups. Two-way repeated-measures ANOVA was used to analyze changes before and after the intervention. When significant interactions were found, post hoc comparisons using Tukey–Kramer’s method were applied. Paired-sample t-tests assessed pre-post changes within each group. Correlation analyses between physical/cognitive outcomes and step counts were performed using Pearson’s correlation for normally distributed data and Spearman’s rank correlation for non-normal or ordinal data. Statistical significance was set at p < 0.05. All analyses were conducted using SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). 3. Results Fig. 2 presents the average monthly total daily steps and exercise steps recorded during the health education programs conducted in Thailand, the Philippines, Matsumoto City, and Minowa Town, Japan. **[Insert Fig. 2 here]** 3-1. Results – Step Count Trends Across Sites In Thailand, participants’ physical activity steadily increased over the nine-month period, starting from 6,455 ± 234 daily steps and 3,378 ± 146 exercise steps in January, and reaching 8,088 ± 551 and 4,799 ± 360 respectively by September. In the Philippines, daily step counts fluctuated moderately across the year, ranging from 4,904 ± 122 to 6,917 ± 190. However, exercise steps remained relatively low, between 783 ± 50 and 2,221 ± 77, indicating less time spent in moderate-to-vigorous physical activity. In Matsumoto City, Japan, participants maintained consistent activity levels, with daily steps ranging from 5,649 ± 468 to 6,818 ± 406, and exercise steps from 3,704 ± 411 to 4,407 ± 350. In contrast, Minowa Town recorded the highest average total daily step counts among all regions, ranging from 8,366 ± 403 in May to 8,937 ± 499 in June. Exercise steps were moderately high, between 2,702 ± 361 and 4,377 ± 508. The mean total daily steps and exercise steps across the entire program period were as follows: ・Thailand: 6,969 ± 86 steps/day; 3,852 ± 53 exercise steps/day ・Philippines: 6,094 ± 84 steps/day; 1,289 ± 20 exercise steps/day ・Matsumoto City: 6,339 ± 134 steps/day; 4,074 ± 114 exercise steps/day ・Minowa Town: 8,701 ± 173 steps/day; 3,515 ± 162 exercise steps/day As shown in Table 3, Minowa participants had significantly more total daily steps than those in the other three locations (p < 0.001). Thailand also had significantly higher daily steps than the Philippines (p < 0.001). Regarding exercise steps, Matsumoto recorded significantly more than both the Philippines and Minowa (p < 0.001), and Thailand had significantly more than the Philippines (p < 0.001) and slightly more than Minowa. Table 4 presents the measurements taken before and after the health education interventions across the four regions, with statistically significant values indicated by an asterisk (*). In Thailand, participants showed significant improvements in BMI and 6-minute walk performance. In the Philippines, weight and abdominal circumference improved significantly; however, the 10-meter obstacle walk time became significantly slower. In the Matsumoto group, abdominal circumference decreased significantly, but both systolic and diastolic blood pressure increased. In Minowa Town, significant improvements were observed in weight, BMI, abdominal circumference, sit-ups, eyes-open single-leg stance, 10-meter obstacle walk, and 6-minute walk. Table 5 presents the relationships between variables measured before and after the health education program, focusing on those with a correlation coefficient of 0.4 or higher. Significant positive correlations were observed between age and the number of daily steps (R = 0.40, p < 0.001), weight and abdominal circumference (R = 0.59, p < 0.001), BMI and abdominal circumference (R = 0.60, p < 0.001), systolic and diastolic blood pressure (R = 0.41, p < 0.001), total number of missed responses and reaction time (R = 0.63, p < 0.001), and number of errors and reaction time (R = 0.40, p < 0.001). 4. Discussion This study aimed to promote health among working-age adults and older adults through health education programs conducted in Thailand, the Philippines, and two regions of Japan. While all four regions showed some degree of improvement, the most notable results were observed in Minowa Town, Japan. Participants there, with an average age of 73 years, achieved a daily step average of 8,701 steps—markedly higher than in other regions—and showed significant improvements in multiple physical and cognitive indicators. These remarkable improvements observed among participants in Minowa Town may be attributed to the region’s long-standing community health program, which has been continuously implemented since 2008 with support from multidisciplinary professionals. Several contributing factors likely include: strong peer support that encouraged participants to share and sustain their health goals; trusted relationships with healthcare staff fostered through annual face-to-face communication; a community-wide culture of health that normalized healthy behaviors; and institutional stability that ensured adequate staffing (one staff member per five participants) and professional continuity. These elements collectively supported long-term behavioral change, not only through individual effort, but also through an environment that nurtured mutual encouragement and social accountability. In contrast, participants in Thailand and the Philippines—though younger on average—walked fewer daily steps. This may reflect barriers such as limited walking infrastructure, safety concerns, or sedentary work environments. Nevertheless, both regions showed certain improvements, suggesting that even short-term educational interventions can yield positive outcomes. Both reaction time and commission errors in the go/no-go task were significantly correlated (R = 0.40–0.63), underscoring the link between physical activity and cognitive inhibitory control. Previous studies suggest that walking 7,000 or more steps per day may enhance prefrontal cortex function and reduce cognitive errors [ 24 – 25 ]. However, the optimal number of steps likely varies by age and context. The World Health Organization and Japan’s Ministry of Health, Labour and Welfare have recommended 60–150 minutes of physical activity per day [ 21 – 23 ]. Meanwhile, studies have reported a significant decline in exercise habits and daily step counts among the Japanese population [ 26 – 29 ]. In addition to physical benefits, regular physical activity has been associated with improvements in cognitive function [ 30 – 31 ]. Ultimately, this study suggests that sustained, community-based support systems—characterized by social capital and professional engagement—are essential for achieving long-term health improvements, particularly among older adults [ 32 – 36 ]. 5. Limitations This study has several limitations that should be acknowledged. First, the sample size, age distribution, and gender ratio differed across the four study regions—Thailand, the Philippines, Matsumoto City, and Minowa Town in Japan. These inconsistencies may have influenced the observed outcomes, making direct comparisons between regions more complex. Second, environmental factors such as temperature, humidity, and seasonal variation differed significantly across countries and may have affected physiological measures such as blood pressure and physical activity levels. Third, the participant groups varied by type: working-age adults in Thailand and the Philippines, and elderly individuals in the two Japanese sites. These differences in participant characteristics limit the generalizability of the findings and complicate cross-regional comparisons. Fourth, the timing of data collection was not synchronized across sites, as it depended on the availability of collaborating institutions and staff. This lack of uniformity may have introduced temporal biases related to seasonality or intervention duration. Fifth, the study did not include a formal control group, which limits the ability to draw causal inferences about the effects of the health education interventions. The findings should therefore be interpreted as correlational rather than causal. Finally, public health systems, healthcare accessibility, and urban infrastructure vary across the three countries. Future studies should consider these socio-environmental factors more explicitly and aim to harmonize study designs by employing larger, demographically matched samples and standardized intervention periods. 6. Conclusion The aim of this study was to improve the health levels of workers and elderly individuals by introducing health education guidelines in line with the requirements for health education for workers in the Sampran region of Thailand and the Cebu region of the Philippines and for elderly individuals in Matsumoto City and Minowa Town, Japan. The participants underwent anthropometric measurements, blood pressure, tests, and tests before and after the 8-month and 12-month study periods. In Thailand, the average age was 40 years, and after health education, the average number of steps per day was 6969 steps, and BMI and 6-minute walking time improved significantly. In the Philippines, the average age was 36 years, the average number of steps was 6094, the weight and abdominal area improved significantly, but the 10-m obstacle walking time was significantly delayed. In Matsumoto, the average age was 67 years, the average number of steps was 6339, the abdominal area improved significantly, but the systolic and diastolic blood pressures increased significantly. In Minowa Town, where the average participant age was 73 and the average daily step count reached 8,701, significant improvements were observed in physical functions such as weight, BMI, muscle strength, balance, and endurance. These findings suggest that well-structured health education programs can lead to measurable health benefits. However, walking more does not always guarantee improvement, as the optimal number of steps may vary depending on age. In other words, the critical issue may not be the numerical target of 7,000 steps itself, but rather how well participants understand the importance of health and develop the capacity to integrate this understanding into their daily practice. Declarations Ethics approval and consent to participate This study was approved by the following ethics committees: Mahidol University, Thailand (Approval No. 01-58-10) Chong Hua Hospital, Philippines (Approval No. IRB1389-09) Shinshu University, Japan (Approval No. 180; April 14, 2017) All participants provided written informed consent prior to participation. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are stored in controlled-access storage at Shinshu University and are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding This research was supported by the Ministry of Education, Culture, Sports, Science and Technology (MEXT) of Japan under the following Grants-in-Aid for Scientific Research: 25257101 (2013–2015) 26560380 (2014–2016) 16H02713 (2016–2018) Authors' contributions Suchinda Jarupat Maruo and Koji Terasawa designed the study and drafted the manuscript. Other authors contributed to data collection, analysis, or interpretation. All authors reviewed and approved the final manuscript. Acknowledgements We thank the staff and collaborators of Mahidol University (Thailand), Southwestern University and Gullas College of Medicine (Philippines), and Shinshu University (Japan) for their contributions to this research. References World Health Organization. GHE: Life expectancy and healthy life expectancy. Geneva: WHO. 2022. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-life-expectancy-and-healthy-life-expectancy [accessed 30 Jun. 2025]. Agudelo-Botero M, Dávila-Cervantes AC, Velasco-Calderón O, Giraldo-Rodríguez L. Divergences and gaps in life expectancy and health-adjusted life expectancy in Mexico: Contribution analysis of the Global Burden of Disease Study 2019. PLoS ONE. 2023;18(11):e0293881. 10.1371/journal.pone.0293881 . Rasmussen B, Sweeny K, Sheehan P. Health and economy: The impact of wellness on workforce productivity in global markets. Washington DC: U.S. Chamber of Commerce, Global Initiative on Health and Economy; 2016. Griffin KW, Botvin GJ. Evidence-based interventions for preventing substance use disorders in adolescents. Child Adolesc Psychiatr Clin N Am. 2010;19(3):505–26. 10.1016/j.chc.2010.03.005 . McDaid D, Sassi F, Merkur S. Promoting health, preventing disease. Geneva: World Health Organization; 2015. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-life-expectancy-and-healthy-life-expectancy [accessed 30 Jun. 2025]. Alli OB. Fundamental principles of occupational health and safety. 2nd ed. Geneva: International Labour Office; 2008. pp. 1–221. Watanabe T, Terasawa K, Nakade K, Murata Y, Terasawa S, Kobayashi I, et al. Influence of two different health promotion programs on walking steps, anthropometry, blood pressure, physical fitness, blood chemistry and brain function. Int J Med Health Sci. 2015;5:170–81. Murata Y, Nemoto K, Kobayashi I, Miyata Y, Terasawa S, Sasamori S, et al. Effect of a two-year health program on brain function, physical fitness and blood chemistry. Med Health Educ. 2016;5:1–6. 10.4172/2161-0711.1000349 . Nakade K, Fujimori S, Watanabe T, Murata Y, Terasawa S, Maruo SJ, et al. A case study of health education from Nagano Prefecture in Japan: The relationship between health education and medical expenses. J Community Med Health Educ. 2017;7(3):1–6. 10.4172/2161-0711.1000529 . (accessed 30 Dec. 2024). Fujimori S, Ashida K, Watanabe N, Nishino T, Sasamori F, Okuhara M, et al. Human rights health care measures reporting physical fitness test for ages 6 to 17 with 10-year follow-up. Int J Hum Rights Healthc. 2024. 10.1108/IJHRH-12-2023-0092 . Watanabe N, Kamijo M, Nishino N, Ashida K, Sasamori F, Okuhara M, et al. The feasibility of using the go/no-go task as a dementia screening test assessed with a cross-sectional design. Sci Rep. 2024;14:29834. 10.1038/s41598-024-81301-5 . Fujimori S, Maruo JS, Piaseu N, Kalampakorn S, Sasimonthonkul S, Nakade K, et al. The effectiveness of a Japanese style health program: comparison between Minowa, Japan and Rayong, Thailand. Heliyon. 2017;4:e00961. Fujimori S, Maruo JS, Watanabe T, Taki N, Sasamori F, Kobayashi K, et al. Effectiveness of a Japanese-style health program in Minowa Town, Matsumoto city and Nagano city, Japan. Int J Hum Rig Healcar. 2020;1–17. https://doi.org/10.1108/IJHRH-01-2020-0002 . Maruo JS, Sanongdetch W, Choeychom S, Chansirikarn S, Thrakul S, Phuphaibul R, et al. Comparing the effectiveness of health program in Thailand and Japan. J Nurs Care. 2015;4(5):1–6. https://doi.org/10.4172/2167-1168.1000298 . Adiatmika IG, Terasawa K, Maruo SJ, Nakade K, Watanabe T, Terasawa S, et al. The effect of health education as non-pharmacological therapy on physical fitness, blood chemistry and brain function among senior citizen in both rural and urban areas of Bali, Indonesia. Int J Pharm Pharm Sci. 2021;13(2):24–8. https://doi.org/10.22159/ijpps.2021v13i2.40151 . Maruo JS, Noppawan P, Surintom K, Pinyo U, Siripon S, Tabuchi H, et al. The effectiveness of a health promotion program using the International Organization for Standardization in Klongyong and Nikhompattana, Thailand. Asian J Pharm Clin Res. 2020;13(3):1–6. https://doi.org/10.22159/ajpcr.2020.v13i3.36506 . Terasawa K, Gede AIP, Nyoman AI, Maruo SJ, Kalampakorn S, Watanabe T, et al. Implementation of a health education program in Asia, comparing Thailand, Indonesia, and Japan. Technol Health Care. 2022;30(4):775–85. https://doi.org/10.3233/THC-202583 . Aznar SP, Nino ISP, Sergio JRS, Rigan AP-A, Maruo JS, Sasamori F, et al. A report on attempts to acquire exercise habits through Japanese health education for adult workers from Cebu, Philippines. Health Scope. 2023;12(4). https://doi.org/10.5812/healthscope-134198 . Ministry of Education, Culture, Sports, Science and Technology. New physical fitness test (for 65–79 years old). 1999. Available from: https://www.mext.go.jp/component/a_menu/sports/detail/__icsFiles/afieldfile/2010/07/30/1295079_04.pdf [accessed 30 Jun. 2025]. Masaki T, Moriyama G. Study on types of human higher nervous activity. Tokyo Univ Sci Press. 1971;4:69–81. (in Japanese). Ministry of Health, Labor and Welfare. Health Japan 21. Available from: https://www.mhlw.go.jp/www1/topics/kenko21_11/s0.html [accessed 30 Jun. 2025]. World Health Organization (WHO). Physical activity. Available from: https://www.who.int/news-room/fact-sheets/detail/physical-activity [accessed 30 Jun. 2025]. Ministry of Health, Labor and Welfare. Physical activity and exercise. Available from: https://www.mhlw.go.jp/www1/topics/kenko21_11/b2.html [accessed 30 Jun. 2025]. Banach M, Lewek J, Surma S, Penson EP, Sahebkar A, Martin SS, et al. The association between daily step count and all-cause and cardiovascular mortality: a meta-analysis. Eur J Prev Cardiol. 2023;30(18):1975–85. https://doi.org/10.1093/eurjpc/zwad229 . Paluch EA, Gabriel KP, Fulton JE, Lewis CE, Schreiner PJ, Sternfeld B, et al. Steps per day and all-cause mortality in middle-aged adults in the Coronary Artery Risk Development in Young Adults study. JAMA Netw Open. 2021;4(9):e2124516. 10.1001/jamanetworkopen.2021.24516 . Ministry of Health, Labor and Welfare. Health information site for preventing lifestyle-related diseases. Average life expectancy and healthy life expectancy. Available from: https://www.e-healthnet.mhlw.go.jp/information/hale/h-01-002.html [accessed 30 Jun. 2025]. Ministry of Health, Labor and Welfare of Japan. Longitudinal survey of middle-aged and elderly people. 2010. Available from: https://www.mhlw.go.jp/toukei/saikin/hw/judan/chukou18/dl/sankou.pdf [accessed 30 Jun. 2025]. Ministry of Health, Labor and Welfare of Japan. Longitudinal survey of middle-aged and elderly people. 2010. Available from: https://www.mhlw.go.jp/toukei/saikin/hw/judan/chukou18/dl/sankou.pdf [accessed 30 Jun. 2025]. Longitudinal Survey of Middle-aged and Elderly People. Ministry of Health, Labor and Welfare of Japan. 2017. Available from: https://www.mhlw.go.jp/toukei/saikin/hw/judan/chukou06/toukei.htm [accessed 30 Jun. 2025]. Nemin C, Caterina R, Helmet TK, Stephanie AS, Andrea LR. Regional gray matter density associated with fast-paced walking in older adults: a voxel-based morphometry study. J Gerontol Biol Sci Med Sci. 2020;75(8):1530–6. https://doi.org/10.1093/gerona/glaa091 . Joaquin UG, Kareem Al-K, Michael O. Spatial task-related brain activity and its association with preferred and fast-paced gait speed in older adults. Neurosci Lett. 2019;713:134526. https://doi.org/10.1016/j.neulet.2019.134526 . Nakade K, Abe K, Fujiwara T, Terasawa K, Okuhara M, Nakajima M, et al. The influence of two different health education programs on go/no-go tasks, physical fitness test and blood test. Japan Soci Physio Anthro. 2009;14:3. (Japanese). Egolf B, Lasker J, Wolf S, Potvin L. The Roseto effect: a 50-year comparison of mortality rates. Am J Public Health. 1992;82(8):1089–92. 10.2105/ajph.82.8.1089 . Vaillant EG. Triumphs of Experience: The Men of the Harvard Grant Study. Cambridge, MA: Belknap Press of Harvard University Press; 2015. pp. 1–480. ISBN: 9780674503816. Moyers B. Healing and the Mind. New York: Doubleday; 1993. pp. 23–143. ISBN: 0385468709. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet. 1989;334(8668):888–91. 10.1016/S0140-6736(89)91551-1 . Tables Table 1 ． Monthly health education activities conducted in Thailand, the Philippines, and two regions in Japan Month Thailand Philippine s Matsumoto City Minowa Town January ①Physical education ⑥Mental health ⑨Dementia prevention exercise February ②Personal hygiene March ③Health counseling ①Nutrition April ④Recreations May ⑤First aids and heat stroke ②Hypertension ①Exercise habits class ①Walking Lessons Jun e ⑥Nutrition ②Recreations ②Hypertension July ⑦Occupational health education ③Diabetes ③Baseball practice class ③Physical education August ⑧Mental health ④Mallet Golf ④Excursion September ⑨Health counseling ④Mental health ⑤Dementia Lectures ⑤Nutritional cooking class October ⑥Physical education ⑥Recreations November ⑦Excursion ⑦Dementia prevention exercise December ⑤Mental health ⑧Aerobics ⑧Health counseling Note: Circled numbers indicate the order in which activities were introduced Table 2. Participant Country Age Male Female Total Number Thailand 39.8±7.3 4 9 13 Philippines 35.6±7.0 12 21 43 Japan (Matsumoto) 67.3±6.7 14 52 66 Japan (Minowa) 72.6±4.0 15 33 48 Table 3. Mean Daily Steps and Exercise Steps Across Four Regions Thailand Philippines Matsumoto Minowa ANOVA (p-value) Tukey- K ramer Post-hoc Results p < 0.05 p < 0.01 Steps 6969±86 6094±84 6339±134 8701±173 0.001 I vs.T, I vs.P, I vs.A, T vs.P Exercise 3852±53 1289±20 4074±114 3515±162 0.001 T vs.I A vs.P, A vs.I, T vs.P, I vs. P Values are shown as mean ± standard error. T: Thailand, P: Philippines, A: Matsumoto, I: Minowa, E: Exercise steps. p values from one-way ANOVA. Tukey-Kramer post hoc test used for pairwise comparisons. Table 4 is available in the Supplementary Files section. Table 5. Pairwise correlations (r ≥ 0.4) between health and cognitive measures ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ Age (①) - - - - - - - - - - Steps (②) 0.40*** - - - - - - - - - Weight (③) - - - - - - - - - - Abdominal (④) - - 0.59*** - - - - - - - BMI (⑤) - - - 0.60*** - - - - - - Systolic (⑥) - - - - - - - - - - Diastolic (⑦) - - - - - 0.41*** - - - - Av. Reac. (⑧) - - - - - - - - - - Total missing (⑨) - - - - - - - 0.63*** - - Total error (⑩) - - - - - - - 0.40*** - - Av. reac; Average reaction, ***; p<0.001 Additional Declarations No competing interests reported. Supplementary Files Table41.docx Cite Share Download PDF Status: Published Journal Publication published 22 Nov, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 08 Oct, 2025 Reviews received at journal 30 Sep, 2025 Reviews received at journal 24 Sep, 2025 Reviewers agreed at journal 18 Aug, 2025 Reviewers agreed at journal 18 Jul, 2025 Reviewers invited by journal 17 Jul, 2025 Editor invited by journal 09 Jul, 2025 Editor assigned by journal 09 Jul, 2025 Submission checks completed at journal 09 Jul, 2025 First submitted to journal 02 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7027881","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":488346208,"identity":"aad9ef36-9af2-43fd-ba23-fe4100422387","order_by":0,"name":"Suchinda Jarupat 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University","correspondingAuthor":false,"prefix":"","firstName":"Kwanjai","middleName":"","lastName":"Amnatsatsue","suffix":""},{"id":488346210,"identity":"fc408bc5-e008-494f-a831-3c33948b8e35","order_by":2,"name":"Weha Kasemsuk","email":"","orcid":"","institution":"Mahidol University","correspondingAuthor":false,"prefix":"","firstName":"Weha","middleName":"","lastName":"Kasemsuk","suffix":""},{"id":488346211,"identity":"5ca74384-1f1d-42c2-be40-2299970fbe56","order_by":3,"name":"Peter S Aznar","email":"","orcid":"","institution":"Southwestern University Phinma","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"S","lastName":"Aznar","suffix":""},{"id":488346212,"identity":"12d25c1f-e836-45fe-bc75-0d263d48e813","order_by":4,"name":"S Nino Ismael","email":"","orcid":"","institution":"Gullas College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"S","middleName":"Nino","lastName":"Ismael","suffix":""},{"id":488346213,"identity":"d8cd5172-50f9-43e8-a9f5-a0e090ff7d3f","order_by":5,"name":"Fumihito Sasamori","email":"","orcid":"","institution":"Shinshu University","correspondingAuthor":false,"prefix":"","firstName":"Fumihito","middleName":"","lastName":"Sasamori","suffix":""},{"id":488346214,"identity":"4c5724b7-39dd-4d43-a93e-322a0615bf6b","order_by":6,"name":"Kazuki Ashida","email":"","orcid":"","institution":"National Institute of Technology, Nagano College","correspondingAuthor":false,"prefix":"","firstName":"Kazuki","middleName":"","lastName":"Ashida","suffix":""},{"id":488346215,"identity":"802a85f2-4551-4743-9987-c72b4e95384a","order_by":7,"name":"Masao Okuhara","email":"","orcid":"","institution":"Suwa University of Science","correspondingAuthor":false,"prefix":"","firstName":"Masao","middleName":"","lastName":"Okuhara","suffix":""},{"id":488346216,"identity":"e5d6c99d-4739-46c2-94e5-93dd3f9121d8","order_by":8,"name":"Hisaaki Tabuchi","email":"","orcid":"","institution":"Shinshu University","correspondingAuthor":false,"prefix":"","firstName":"Hisaaki","middleName":"","lastName":"Tabuchi","suffix":""},{"id":488346217,"identity":"8a858ccd-0bc5-4058-a842-1b8c49312864","order_by":9,"name":"Koji Terasawa","email":"","orcid":"","institution":"University of Innsbruck","correspondingAuthor":false,"prefix":"","firstName":"Koji","middleName":"","lastName":"Terasawa","suffix":""}],"badges":[],"createdAt":"2025-07-02 09:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7027881/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7027881/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-25496-w","type":"published","date":"2025-11-22T15:57:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87345844,"identity":"cce38aa9-8946-42d5-bd72-7f0023de10b3","added_by":"auto","created_at":"2025-07-23 02:22:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":567488,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Picture1.png","url":"https://assets-eu.researchsquare.com/files/rs-7027881/v1/999a5e040628d814db0a2749.png"},{"id":87345457,"identity":"cbc873dc-4d5c-492e-b6ee-2edf34c2de67","added_by":"auto","created_at":"2025-07-23 02:14:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":85855,"visible":true,"origin":"","legend":"\u003cp\u003eAverage monthly total daily steps and exercise steps across four regions during the health education programs.\u003c/p\u003e","description":"","filename":"Picture2.png","url":"https://assets-eu.researchsquare.com/files/rs-7027881/v1/d2a552b08bb60cc5f66b4f57.png"},{"id":96651204,"identity":"8c92b942-1952-4c1a-8401-7c70f625b76e","added_by":"auto","created_at":"2025-11-24 16:14:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1352050,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7027881/v1/7ca2a873-cd7b-42c3-ad3d-964fe3d17828.pdf"},{"id":87345460,"identity":"6b5532f2-46d6-4ea9-9fce-42628165198d","added_by":"auto","created_at":"2025-07-23 02:14:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":47287,"visible":true,"origin":"","legend":"","description":"","filename":"Table41.docx","url":"https://assets-eu.researchsquare.com/files/rs-7027881/v1/4725fecf0f1192b5b9d9abe8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health education interventions across Thailand, the Philippines, and Japan: A multisite comparison in varying socio-environmental and policy contexts","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eGlobally, life expectancy increased from 66.8 years in 2000 to 73.4 years in 2019, while healthy life expectancy (HALE) rose from 58.3 to 63.7 years. However, this gain in HALE lagged behind the overall increase in life expectancy, mainly due to declining mortality rather than reductions in years lived with disability. The COVID-19 pandemic reversed these gains, lowering life expectancy and HALE to 71.4 and 61.9 years, respectively, in 2021\u0026mdash;levels comparable to those in 2012 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These trends highlight the urgent need to enhance health standards and extend HALE globally [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImproving population health has major socioeconomic implications. In Japan, for example, absenteeism, presenteeism (working while sick), and early retirement due to poor health contribute to a 7% loss in GDP, amounting to \u003cspan\u003e$\u003c/span\u003e370 billion\u0026mdash;nearly 38% of the national budget [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Enhancing public health not only improves quality of life but can also stimulate economic growth.\u003c/p\u003e\u003cp\u003eStudies suggest that individuals who participate in comprehensive health education programs are less likely to adopt harmful behaviors such as excessive alcohol intake, smoking, or drug use [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Occupational safety and health (OSH) is defined as the anticipation, recognition, evaluation, and control of workplace hazards that may affect worker well-being and surrounding communities [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The International Labour Organization recommends workplace health promotion programs to reduce illness- and accident-related costs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn 2019, HALE was estimated at approximately 63 years in Thailand, 61 years in the Philippines, and 72 years in Japan. Since 1988, we have implemented dementia prevention programs as part of community-based health education in five regions of Nagano Prefecture, Japan. These initiatives promoted empathy and cooperation, using a social capital-oriented framework [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Since 2013, our program has been adapted for communities near Mahidol University (Thailand), Udayana University (Indonesia), and Southwestern University (Philippines). We adopted the PDCA (Plan\u0026ndash;Do\u0026ndash;Check\u0026ndash;Act) cycle for quality assurance and obtained ISO 9001 certification in 2014 (self-declaration since 2021) [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary aim of this study is to evaluate the effects of standardized health education programs on physical and cognitive health among older adults and working-age individuals across four diverse regions: Sampran (Thailand), Cebu (Philippines), Matsumoto City, and Minowa Town (Japan).\u003c/p\u003e"},{"header":"2. Method","content":"\u003cp\u003e2-1. General methods\u003c/p\u003e\n\u003cp\u003eThis quasi-experimental pre-post study was conducted as a health education intervention from March 2017 to February 2018 across four sites: Sampran (Thailand), Cebu (Philippines), Matsumoto City, and Minowa Town (Japan). Participants were recruited through public announcements and information sessions organized in cooperation with local governments and universities. Only individuals who provided written informed consent were included. Random sampling was not feasible due to logistical constraints, so convenience sampling was used. Although the sample size was not statistically predetermined, efforts were made to ensure sufficient representation from each site, and baseline characteristics were collected to confirm demographic comparability where possible. Descriptive statistics and post-hoc power analyses were employed to assess the adequacy of sample sizes for detecting within-group changes.\u003c/p\u003e\n\u003cp\u003eThe duration and participant characteristics at each site were as follows:\u003c/p\u003e\n\u003cp\u003e・Sampran, Thailand (January\u0026ndash;September 2017): 13 participants (mean age: 39.8 \u0026plusmn; 7.3 years; 4 men [34.3 \u0026plusmn; 4.3 years], 9 women [42.3 \u0026plusmn; 7.0 years])\u003c/p\u003e\n\u003cp\u003e・Cebu, Philippines (March 2017\u0026ndash;February 2018): 43 participants (mean age: 35.6 \u0026plusmn; 7.0 years; 22 men [36.4 \u0026plusmn; 7.0 years], 21 women [34.8 \u0026plusmn; 7.2 years])\u003c/p\u003e\n\u003cp\u003e・Matsumoto City, Japan (May 2017\u0026ndash;February 2018): 66 participants (mean age: 67.3 \u0026plusmn; 6.7 years; 14 men [70.7 \u0026plusmn; 5.9 years], 52 women [66.3 \u0026plusmn; 6.6 years])\u003c/p\u003e\n\u003cp\u003e・Minowa Town, Japan (May\u0026ndash;December 2017): 48 participants (mean age: 72.6 \u0026plusmn; 4.0 years; 15 men [73.5 \u0026plusmn; 4.6 years], 33 women [72.3 \u0026plusmn; 3.8 years])\u003c/p\u003e\n\u003cp\u003eEach program followed a standardized structure consisting of baseline and post-program measurements, physical exercise demonstrations, and health education lectures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe overall intervention design is outlined in **Fig. 1**, and demographic and timeline information is shown in Tables 1 and 2. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Insert Fig. 1 here]\u003c/p\u003e\n\u003cp\u003e2.2 Ethical Considerations\u003c/p\u003e\n\u003cp\u003eParticipation in this study was entirely voluntary, and individuals could withdraw at any time without any penalty. Prior to participation, all subjects received a detailed explanation of the study objectives, procedures, and potential risks. Written informed consent was obtained from each participant, and all data were treated confidentially in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the ethics committees of Mahidol University in Thailand (No. 01-58-10), Chong Hua Hospital in Cebu City, Philippines (IRB1389-09), and Shinshu University in Japan (Approval No. 180; April 14, 2017). All procedures were conducted in accordance with institutional and international ethical standards.\u003c/p\u003e\n\u003cp\u003eHuman Ethics and Consent to Participate declarations: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants prior to data collection. The study was approved by the following ethics committees: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Mahidol University, Thailand (Approval No. 01-58-10) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Chong Hua Hospital, Philippines (Approval No. IRB1389-09) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Shinshu University, Japan (Approval No. 180; April 14, 2017)\u003c/p\u003e\n\u003cp\u003e2.3 Pedometer-Based Physical Activity Measurement\u003c/p\u003e\n\u003cp\u003eDaily physical activity was monitored using a pedometer (JP800, Acos Co., Ltd., Japan) throughout the intervention period. Step counts were categorized based on metabolic equivalents (METs): \u0026ldquo;walking\u0026rdquo; steps (fewer than 4 METs) and \u0026ldquo;exercise\u0026rdquo; steps (equal to or greater than 4 METs), where 1 MET represents energy expenditure while sitting at rest.\u003c/p\u003e\n\u003cp\u003e2.4 Anthropometry, Blood Chemistry, and Blood Pressure\u003c/p\u003e\n\u003cp\u003eAnthropometric measurements, including body weight and BMI, were recorded using a body composition monitor (HBF-359, Omron Healthcare Co., Ltd., Japan). Blood chemistry parameters were assessed in the fasting state (\u0026gt;10 hours). Systolic and diastolic blood pressure were measured using a mercury sphygmomanometer (Kenzumedico 0601B001, Japan) after participants had been seated at rest for 15 minutes in a temperature-controlled room (25\u0026deg;C, 50% relative humidity).\u003c/p\u003e\n\u003cp\u003e2.5 Physical Fitness Assessments\u003c/p\u003e\n\u003cp\u003ePhysical fitness was assessed using the standardized \u0026ldquo;New Physical Fitness Test\u0026rdquo; for older adults, developed by the Japanese Ministry of Education, Culture, Sports, Science and Technology [19]. Six performance tests were conducted before and after the program:\u003c/p\u003e\n\u003cp\u003e・Hand grip strength (T.K.K.5001, Grip-A; muscle strength)\u003c/p\u003e\n\u003cp\u003e・Sit-ups (muscle endurance)\u003c/p\u003e\n\u003cp\u003e・Sit-and-reach test (Toei Light, T2421; flexibility)\u003c/p\u003e\n\u003cp\u003e・Eyes-open, single-leg stance (balance ability)\u003c/p\u003e\n\u003cp\u003e・10-meter obstacle walk (walking ability)\u003c/p\u003e\n\u003cp\u003e・Six-minute walk test (aerobic endurance)\u003c/p\u003e\n\u003cp\u003eThese assessments were used collectively to evaluate changes in overall physical fitness.\u003c/p\u003e\n\u003cp\u003e2.6 Cognitive Function Test: Go/No-Go Task\u003c/p\u003e\n\u003cp\u003eCognitive inhibitory control was evaluated using a go/no-go task device developed by the Faculty of Engineering at Shinshu University [11, 17, 20]. The test comprised three stages:\u003c/p\u003e\n\u003cp\u003e1. Formation stage (5 trials): Squeeze a rubber ball in response to a red light.\u003c/p\u003e\n\u003cp\u003e2. Differentiation stage (20 trials): Respond to red light and withhold response to yellow.\u003c/p\u003e\n\u003cp\u003e3. Reverse differentiation stage (20 trials): Respond to yellow light and withhold response to red.\u003c/p\u003e\n\u003cp\u003eIn the latter two stages, red and yellow lights were each presented 10 times at random. Stimuli were presented at intervals of 2.5 to 3.5 seconds, randomly varied to prevent anticipatory responses. Each participant completed the task in approximately 3\u0026ndash;4 minutes, including brief instructions and setup time. The test was conducted in a quiet room maintained at approximately 25 \u0026deg;C and 50% relative humidity, under standardized lighting conditions. Participants were seated at a standard desk approximately 60\u0026ndash;70 cm high, and received standardized verbal instructions prior to the test. In this study, a \u0026quot;missing\u0026quot; (i.e., omission) was defined as a failure to respond to a Go stimulus, and a \u0026quot;mistake\u0026quot; (i.e., commission error) as an inappropriate response to a No-Go stimulus. The total number of errors was calculated as the sum of omissions and commission errors.\u003c/p\u003e\n\u003cp\u003e2.7 Statistical Analysis\u003c/p\u003e\n\u003cp\u003eOne-way analysis of variance (ANOVA) was used to compare step counts among the four regional groups. Two-way repeated-measures ANOVA was used to analyze changes before and after the intervention. When significant interactions were found, post hoc comparisons using Tukey\u0026ndash;Kramer\u0026rsquo;s method were applied. Paired-sample t-tests assessed pre-post changes within each group. Correlation analyses between physical/cognitive outcomes and step counts were performed using Pearson\u0026rsquo;s correlation for normally distributed data and Spearman\u0026rsquo;s rank correlation for non-normal or ordinal data. Statistical significance was set at p \u0026lt; 0.05. All analyses were conducted using SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eFig. 2 presents the average monthly total daily steps and exercise steps recorded during the health education programs conducted in Thailand, the Philippines, Matsumoto City, and Minowa Town, Japan.\u003c/p\u003e\n\u003cp\u003e**[Insert Fig. 2 here]** \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3-1. Results \u0026ndash; Step Count Trends Across Sites\u003c/p\u003e\n\u003cp\u003eIn Thailand, participants\u0026rsquo; physical activity steadily increased over the nine-month period, starting from 6,455 \u0026plusmn; 234 daily steps and 3,378 \u0026plusmn; 146 exercise steps in January, and reaching 8,088 \u0026plusmn; 551 and 4,799 \u0026plusmn; 360 respectively by September.\u003c/p\u003e\n\u003cp\u003eIn the Philippines, daily step counts fluctuated moderately across the year, ranging from 4,904 \u0026plusmn; 122 to 6,917 \u0026plusmn; 190. However, exercise steps remained relatively low, between 783 \u0026plusmn; 50 and 2,221 \u0026plusmn; 77, indicating less time spent in moderate-to-vigorous physical activity.\u003c/p\u003e\n\u003cp\u003eIn Matsumoto City, Japan, participants maintained consistent activity levels, with daily steps ranging from 5,649 \u0026plusmn; 468 to 6,818 \u0026plusmn; 406, and exercise steps from 3,704 \u0026plusmn; 411 to 4,407 \u0026plusmn; 350. In contrast, Minowa Town recorded the highest average total daily step counts among all regions, ranging from 8,366 \u0026plusmn; 403 in May to 8,937 \u0026plusmn; 499 in June. Exercise steps were moderately high, between 2,702 \u0026plusmn; 361 and 4,377 \u0026plusmn; 508.\u003c/p\u003e\n\u003cp\u003eThe mean total daily steps and exercise steps across the entire program period were as follows:\u003c/p\u003e\n\u003cp\u003e・Thailand: 6,969 \u0026plusmn; 86 steps/day; 3,852 \u0026plusmn; 53 exercise steps/day\u003c/p\u003e\n\u003cp\u003e・Philippines: 6,094 \u0026plusmn; 84 steps/day; 1,289 \u0026plusmn; 20 exercise steps/day\u003c/p\u003e\n\u003cp\u003e・Matsumoto City: 6,339 \u0026plusmn; 134 steps/day; 4,074 \u0026plusmn; 114 exercise steps/day\u003c/p\u003e\n\u003cp\u003e・Minowa Town: 8,701 \u0026plusmn; 173 steps/day; 3,515 \u0026plusmn; 162 exercise steps/day\u003c/p\u003e\n\u003cp\u003eAs shown in Table 3, Minowa participants had significantly more total daily steps than those in the other three locations (p \u0026lt; 0.001). Thailand also had significantly higher daily steps than the Philippines (p \u0026lt; 0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding exercise steps, Matsumoto recorded significantly more than both the Philippines and Minowa (p \u0026lt; 0.001), and Thailand had significantly more than the Philippines (p \u0026lt; 0.001) and slightly more than Minowa. Table 4 presents the measurements taken before and after the health education interventions across the four regions, with statistically significant values indicated by an asterisk (*). In Thailand, participants showed significant improvements in BMI and 6-minute walk performance. In the Philippines, weight and abdominal circumference improved significantly; however, the 10-meter obstacle walk time became significantly slower. In the Matsumoto group, abdominal circumference decreased significantly, but both systolic and diastolic blood pressure increased. In Minowa Town, significant improvements were observed in weight, BMI, abdominal circumference, sit-ups, eyes-open single-leg stance, 10-meter obstacle walk, and 6-minute walk.\u003c/p\u003e\n\u003cp\u003eTable 5 presents the relationships between variables measured before and after the health education program, focusing on those with a correlation coefficient of 0.4 or higher. Significant positive correlations were observed between age and the number of daily steps (R = 0.40, p \u0026lt; 0.001), weight and abdominal circumference (R = 0.59, p \u0026lt; 0.001), BMI and abdominal circumference (R = 0.60, p \u0026lt; 0.001), systolic and diastolic blood pressure (R = 0.41, p \u0026lt; 0.001), total number of missed responses and reaction time (R = 0.63, p \u0026lt; 0.001), and number of errors and reaction time (R = 0.40, p \u0026lt; 0.001).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study aimed to promote health among working-age adults and older adults through health education programs conducted in Thailand, the Philippines, and two regions of Japan. While all four regions showed some degree of improvement, the most notable results were observed in Minowa Town, Japan. Participants there, with an average age of 73 years, achieved a daily step average of 8,701 steps\u0026mdash;markedly higher than in other regions\u0026mdash;and showed significant improvements in multiple physical and cognitive indicators.\u003c/p\u003e\u003cp\u003e These remarkable improvements observed among participants in Minowa Town may be attributed to the region\u0026rsquo;s long-standing community health program, which has been continuously implemented since 2008 with support from multidisciplinary professionals. Several contributing factors likely include: strong peer support that encouraged participants to share and sustain their health goals; trusted relationships with healthcare staff fostered through annual face-to-face communication; a community-wide culture of health that normalized healthy behaviors; and institutional stability that ensured adequate staffing (one staff member per five participants) and professional continuity. These elements collectively supported long-term behavioral change, not only through individual effort, but also through an environment that nurtured mutual encouragement and social accountability.\u003c/p\u003e\u003cp\u003eIn contrast, participants in Thailand and the Philippines\u0026mdash;though younger on average\u0026mdash;walked fewer daily steps. This may reflect barriers such as limited walking infrastructure, safety concerns, or sedentary work environments. Nevertheless, both regions showed certain improvements, suggesting that even short-term educational interventions can yield positive outcomes.\u003c/p\u003e\u003cp\u003eBoth reaction time and commission errors in the go/no-go task were significantly correlated (R\u0026thinsp;=\u0026thinsp;0.40\u0026ndash;0.63), underscoring the link between physical activity and cognitive inhibitory control. Previous studies suggest that walking 7,000 or more steps per day may enhance prefrontal cortex function and reduce cognitive errors [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, the optimal number of steps likely varies by age and context.\u003c/p\u003e\u003cp\u003eThe World Health Organization and Japan\u0026rsquo;s Ministry of Health, Labour and Welfare have recommended 60\u0026ndash;150 minutes of physical activity per day [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Meanwhile, studies have reported a significant decline in exercise habits and daily step counts among the Japanese population [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In addition to physical benefits, regular physical activity has been associated with improvements in cognitive function [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUltimately, this study suggests that sustained, community-based support systems\u0026mdash;characterized by social capital and professional engagement\u0026mdash;are essential for achieving long-term health improvements, particularly among older adults [\u003cspan additionalcitationids=\"CR33 CR34 CR35\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThis study has several limitations that should be acknowledged. First, the sample size, age distribution, and gender ratio differed across the four study regions\u0026mdash;Thailand, the Philippines, Matsumoto City, and Minowa Town in Japan. These inconsistencies may have influenced the observed outcomes, making direct comparisons between regions more complex. Second, environmental factors such as temperature, humidity, and seasonal variation differed significantly across countries and may have affected physiological measures such as blood pressure and physical activity levels. Third, the participant groups varied by type: working-age adults in Thailand and the Philippines, and elderly individuals in the two Japanese sites. These differences in participant characteristics limit the generalizability of the findings and complicate cross-regional comparisons. Fourth, the timing of data collection was not synchronized across sites, as it depended on the availability of collaborating institutions and staff. This lack of uniformity may have introduced temporal biases related to seasonality or intervention duration.\u003c/p\u003e\u003cp\u003eFifth, the study did not include a formal control group, which limits the ability to draw causal inferences about the effects of the health education interventions. The findings should therefore be interpreted as correlational rather than causal. Finally, public health systems, healthcare accessibility, and urban infrastructure vary across the three countries. Future studies should consider these socio-environmental factors more explicitly and aim to harmonize study designs by employing larger, demographically matched samples and standardized intervention periods.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003e The aim of this study was to improve the health levels of workers and elderly individuals by introducing health education guidelines in line with the requirements for health education for workers in the Sampran region of Thailand and the Cebu region of the Philippines and for elderly individuals in Matsumoto City and Minowa Town, Japan. The participants underwent anthropometric measurements, blood pressure, tests, and tests before and after the 8-month and 12-month study periods. In Thailand, the average age was 40 years, and after health education, the average number of steps per day was 6969 steps, and BMI and 6-minute walking time improved significantly. In the Philippines, the average age was 36 years, the average number of steps was 6094, the weight and abdominal area improved significantly, but the 10-m obstacle walking time was significantly delayed. In Matsumoto, the average age was 67 years, the average number of steps was 6339, the abdominal area improved significantly, but the systolic and diastolic blood pressures increased significantly. In Minowa Town, where the average participant age was 73 and the average daily step count reached 8,701, significant improvements were observed in physical functions such as weight, BMI, muscle strength, balance, and endurance. These findings suggest that well-structured health education programs can lead to measurable health benefits. However, walking more does not always guarantee improvement, as the optimal number of steps may vary depending on age. In other words, the critical issue may not be the numerical target of 7,000 steps itself, but rather how well participants understand the importance of health and develop the capacity to integrate this understanding into their daily practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the following ethics committees:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eMahidol University, Thailand (Approval No. 01-58-10)\u003c/li\u003e\n \u003cli\u003eChong Hua Hospital, Philippines (Approval No. IRB1389-09)\u003c/li\u003e\n \u003cli\u003eShinshu University, Japan (Approval No. 180; April 14, 2017)\u003cbr\u003e\u0026nbsp;All participants provided written informed consent prior to participation.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are stored in controlled-access storage at Shinshu University and are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Ministry of Education, Culture, Sports, Science and Technology (MEXT) of Japan under the following Grants-in-Aid for Scientific Research:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e25257101 (2013\u0026ndash;2015)\u003c/li\u003e\n \u003cli\u003e26560380 (2014\u0026ndash;2016)\u003c/li\u003e\n \u003cli\u003e16H02713 (2016\u0026ndash;2018)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSuchinda Jarupat Maruo and Koji Terasawa designed the study and drafted the manuscript.\u003cbr\u003e\u0026nbsp;Other authors contributed to data collection, analysis, or interpretation.\u003cbr\u003e\u0026nbsp;All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the staff and collaborators of Mahidol University (Thailand), Southwestern University and Gullas College of Medicine (Philippines), and Shinshu University (Japan) for their contributions to this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. GHE: Life expectancy and healthy life expectancy. Geneva: WHO. 2022. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-life-expectancy-and-healthy-life-expectancy\u003c/span\u003e\u003cspan address=\"https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-life-expectancy-and-healthy-life-expectancy\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgudelo-Botero M, D\u0026aacute;vila-Cervantes AC, Velasco-Calder\u0026oacute;n O, Giraldo-Rodr\u0026iacute;guez L. Divergences and gaps in life expectancy and health-adjusted life expectancy in Mexico: Contribution analysis of the Global Burden of Disease Study 2019. PLoS ONE. 2023;18(11):e0293881. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0293881\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0293881\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRasmussen B, Sweeny K, Sheehan P. Health and economy: The impact of wellness on workforce productivity in global markets. Washington DC: U.S. Chamber of Commerce, Global Initiative on Health and Economy; 2016.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGriffin KW, Botvin GJ. Evidence-based interventions for preventing substance use disorders in adolescents. Child Adolesc Psychiatr Clin N Am. 2010;19(3):505\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.chc.2010.03.005\u003c/span\u003e\u003cspan address=\"10.1016/j.chc.2010.03.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcDaid D, Sassi F, Merkur S. Promoting health, preventing disease. Geneva: World Health Organization; 2015. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-life-expectancy-and-healthy-life-expectancy\u003c/span\u003e\u003cspan address=\"https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-life-expectancy-and-healthy-life-expectancy\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlli OB. Fundamental principles of occupational health and safety. 2nd ed. Geneva: International Labour Office; 2008. pp. 1\u0026ndash;221.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatanabe T, Terasawa K, Nakade K, Murata Y, Terasawa S, Kobayashi I, et al. Influence of two different health promotion programs on walking steps, anthropometry, blood pressure, physical fitness, blood chemistry and brain function. Int J Med Health Sci. 2015;5:170\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurata Y, Nemoto K, Kobayashi I, Miyata Y, Terasawa S, Sasamori S, et al. Effect of a two-year health program on brain function, physical fitness and blood chemistry. Med Health Educ. 2016;5:1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4172/2161-0711.1000349\u003c/span\u003e\u003cspan address=\"10.4172/2161-0711.1000349\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNakade K, Fujimori S, Watanabe T, Murata Y, Terasawa S, Maruo SJ, et al. A case study of health education from Nagano Prefecture in Japan: The relationship between health education and medical expenses. J Community Med Health Educ. 2017;7(3):1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4172/2161-0711.1000529\u003c/span\u003e\u003cspan address=\"10.4172/2161-0711.1000529\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. (accessed 30 Dec. 2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFujimori S, Ashida K, Watanabe N, Nishino T, Sasamori F, Okuhara M, et al. Human rights health care measures reporting physical fitness test for ages 6 to 17 with 10-year follow-up. Int J Hum Rights Healthc. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1108/IJHRH-12-2023-0092\u003c/span\u003e\u003cspan address=\"10.1108/IJHRH-12-2023-0092\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatanabe N, Kamijo M, Nishino N, Ashida K, Sasamori F, Okuhara M, et al. The feasibility of using the go/no-go task as a dementia screening test assessed with a cross-sectional design. Sci Rep. 2024;14:29834. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41598-024-81301-5\u003c/span\u003e\u003cspan address=\"10.1038/s41598-024-81301-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFujimori S, Maruo JS, Piaseu N, Kalampakorn S, Sasimonthonkul S, Nakade K, et al. The effectiveness of a Japanese style health program: comparison between Minowa, Japan and Rayong, Thailand. Heliyon. 2017;4:e00961.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFujimori S, Maruo JS, Watanabe T, Taki N, Sasamori F, Kobayashi K, et al. Effectiveness of a Japanese-style health program in Minowa Town, Matsumoto city and Nagano city, Japan. Int J Hum Rig Healcar. 2020;1\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/IJHRH-01-2020-0002\u003c/span\u003e\u003cspan address=\"10.1108/IJHRH-01-2020-0002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaruo JS, Sanongdetch W, Choeychom S, Chansirikarn S, Thrakul S, Phuphaibul R, et al. Comparing the effectiveness of health program in Thailand and Japan. J Nurs Care. 2015;4(5):1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4172/2167-1168.1000298\u003c/span\u003e\u003cspan address=\"10.4172/2167-1168.1000298\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdiatmika IG, Terasawa K, Maruo SJ, Nakade K, Watanabe T, Terasawa S, et al. The effect of health education as non-pharmacological therapy on physical fitness, blood chemistry and brain function among senior citizen in both rural and urban areas of Bali, Indonesia. Int J Pharm Pharm Sci. 2021;13(2):24\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.22159/ijpps.2021v13i2.40151\u003c/span\u003e\u003cspan address=\"10.22159/ijpps.2021v13i2.40151\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaruo JS, Noppawan P, Surintom K, Pinyo U, Siripon S, Tabuchi H, et al. The effectiveness of a health promotion program using the International Organization for Standardization in Klongyong and Nikhompattana, Thailand. Asian J Pharm Clin Res. 2020;13(3):1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.22159/ajpcr.2020.v13i3.36506\u003c/span\u003e\u003cspan address=\"10.22159/ajpcr.2020.v13i3.36506\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTerasawa K, Gede AIP, Nyoman AI, Maruo SJ, Kalampakorn S, Watanabe T, et al. Implementation of a health education program in Asia, comparing Thailand, Indonesia, and Japan. Technol Health Care. 2022;30(4):775\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3233/THC-202583\u003c/span\u003e\u003cspan address=\"10.3233/THC-202583\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAznar SP, Nino ISP, Sergio JRS, Rigan AP-A, Maruo JS, Sasamori F, et al. A report on attempts to acquire exercise habits through Japanese health education for adult workers from Cebu, Philippines. Health Scope. 2023;12(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5812/healthscope-134198\u003c/span\u003e\u003cspan address=\"10.5812/healthscope-134198\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Education, Culture, Sports, Science and Technology. New physical fitness test (for 65\u0026ndash;79 years old). 1999. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mext.go.jp/component/a_menu/sports/detail/__icsFiles/afieldfile/2010/07/30/1295079_04.pdf\u003c/span\u003e\u003cspan address=\"https://www.mext.go.jp/component/a_menu/sports/detail/__icsFiles/afieldfile/2010/07/30/1295079_04.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMasaki T, Moriyama G. Study on types of human higher nervous activity. Tokyo Univ Sci Press. 1971;4:69\u0026ndash;81. (in Japanese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health, Labor and Welfare. Health Japan 21. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/www1/topics/kenko21_11/s0.html\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/www1/topics/kenko21_11/s0.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). Physical activity. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/physical-activity\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/physical-activity\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health, Labor and Welfare. Physical activity and exercise. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/www1/topics/kenko21_11/b2.html\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/www1/topics/kenko21_11/b2.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBanach M, Lewek J, Surma S, Penson EP, Sahebkar A, Martin SS, et al. The association between daily step count and all-cause and cardiovascular mortality: a meta-analysis. Eur J Prev Cardiol. 2023;30(18):1975\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/eurjpc/zwad229\u003c/span\u003e\u003cspan address=\"10.1093/eurjpc/zwad229\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePaluch EA, Gabriel KP, Fulton JE, Lewis CE, Schreiner PJ, Sternfeld B, et al. Steps per day and all-cause mortality in middle-aged adults in the Coronary Artery Risk Development in Young Adults study. JAMA Netw Open. 2021;4(9):e2124516. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2021.24516\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2021.24516\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health, Labor and Welfare. Health information site for preventing lifestyle-related diseases. Average life expectancy and healthy life expectancy. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.e-healthnet.mhlw.go.jp/information/hale/h-01-002.html\u003c/span\u003e\u003cspan address=\"https://www.e-healthnet.mhlw.go.jp/information/hale/h-01-002.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health, Labor and Welfare of Japan. Longitudinal survey of middle-aged and elderly people. 2010. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/judan/chukou18/dl/sankou.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/judan/chukou18/dl/sankou.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health, Labor and Welfare of Japan. Longitudinal survey of middle-aged and elderly people. 2010. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/judan/chukou18/dl/sankou.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/judan/chukou18/dl/sankou.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLongitudinal Survey of Middle-aged and Elderly People. Ministry of Health, Labor and Welfare of Japan. 2017. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/judan/chukou06/toukei.htm\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/judan/chukou06/toukei.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed 30 Jun. 2025].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNemin C, Caterina R, Helmet TK, Stephanie AS, Andrea LR. Regional gray matter density associated with fast-paced walking in older adults: a voxel-based morphometry study. J Gerontol Biol Sci Med Sci. 2020;75(8):1530\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/gerona/glaa091\u003c/span\u003e\u003cspan address=\"10.1093/gerona/glaa091\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoaquin UG, Kareem Al-K, Michael O. Spatial task-related brain activity and its association with preferred and fast-paced gait speed in older adults. Neurosci Lett. 2019;713:134526. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.neulet.2019.134526\u003c/span\u003e\u003cspan address=\"10.1016/j.neulet.2019.134526\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNakade K, Abe K, Fujiwara T, Terasawa K, Okuhara M, Nakajima M, et al. The influence of two different health education programs on go/no-go tasks, physical fitness test and blood test. Japan Soci Physio Anthro. 2009;14:3. (Japanese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEgolf B, Lasker J, Wolf S, Potvin L. The Roseto effect: a 50-year comparison of mortality rates. Am J Public Health. 1992;82(8):1089\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/ajph.82.8.1089\u003c/span\u003e\u003cspan address=\"10.2105/ajph.82.8.1089\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVaillant EG. \u003cem\u003eTriumphs of Experience: The Men of the Harvard Grant Study.\u003c/em\u003e Cambridge, MA: Belknap Press of Harvard University Press; 2015. pp. 1\u0026ndash;480. ISBN: 9780674503816.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoyers B. \u003cem\u003eHealing and the Mind.\u003c/em\u003e New York: Doubleday; 1993. pp. 23\u0026ndash;143. ISBN: 0385468709.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet. 1989;334(8668):888\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(89)91551-1\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(89)91551-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003cstrong\u003e．\u003c/strong\u003e\u003cstrong\u003eMonthly health education activities conducted in Thailand, the Philippines, and two regions in Japan\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThailand\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhilippine\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMatsumoto City\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinowa Town\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJanuary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e①Physical education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e⑥Mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e⑨Dementia prevention exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFebruary\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e②Personal hygiene\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarch\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e③Health counseling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e①Nutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApril\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e④Recreations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e⑤First aids and heat stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e②Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e①Exercise habits class\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e①Walking Lessons\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJun\u003c/strong\u003e\u003cstrong\u003ee\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e⑥Nutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e②Recreations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e②Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJuly\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e⑦Occupational health education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e③Diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e③Baseball practice class\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e③Physical education\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAugust\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e⑧Mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e④Mallet Golf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e④Excursion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeptember\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e⑨Health counseling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e④Mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e⑤Dementia Lectures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e⑤Nutritional cooking class\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOctober\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e⑥Physical education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e⑥Recreations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNovember\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e⑦Excursion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e⑦Dementia prevention exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecember\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e⑤Mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e⑧Aerobics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e⑧Health counseling\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote: Circled numbers indicate the order in which activities were introduced\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Participant\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eCountry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eTotal Number\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eThailand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e39.8\u0026plusmn;7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003ePhilippines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e35.6\u0026plusmn;7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eJapan (Matsumoto)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e67.3\u0026plusmn;6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eJapan (Minowa)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e72.6\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3. Mean Daily Steps and Exercise Steps Across Four Regions\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"916\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThailand\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhilippines\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMatsumoto\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinowa\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;ANOVA\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 311px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTukey-\u003c/strong\u003e\u003cstrong\u003eK\u003c/strong\u003e\u003cstrong\u003eramer\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Post-hoc Results\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep \u0026lt; 0.05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep \u0026lt;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eSteps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e6969\u0026plusmn;86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e6094\u0026plusmn;84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e6339\u0026plusmn;134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e8701\u0026plusmn;173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eI vs.T, I vs.P, I vs.A, T vs.P\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eExercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e3852\u0026plusmn;53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e1289\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e4074\u0026plusmn;114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e3515\u0026plusmn;162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eT vs.I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eA vs.P, A vs.I, T vs.P, I vs. P\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eValues are shown as mean \u0026plusmn; standard error. T: Thailand, P: Philippines, A: Matsumoto, I: Minowa, E: Exercise steps. p values from one-way ANOVA. Tukey-Kramer post hoc test used for pairwise comparisons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 is available in the Supplementary Files section.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Pairwise correlations (r \u0026ge; 0.4) between health and cognitive measures\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e ①\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e ②\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e ③\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e ④\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e ⑤\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e ⑥\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e ⑦\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e ⑧\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e ⑨\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e ⑩\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eAge (①)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eSteps (②)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e0.40*** \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eWeight (③)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eAbdominal (④)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e0.59***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eBMI (⑤)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e0.60***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eSystolic (⑥)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eDiastolic (⑦)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e0.41***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eAv. Reac. (⑧)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eTotal missing (⑨)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e0.63***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.677%;\"\u003e\n \u003cp\u003eTotal error (⑩)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.71971%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.19477%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e0.40***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.55107%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAv. reac; Average reaction, ***; p\u0026lt;0.001\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7027881/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7027881/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis quasi-experimental pre-post study evaluated the health effects of multisite health education interventions implemented in Thailand, the Philippines, and Japan. Standardized programs, based on a shared health education framework, were delivered for 6 to 12 months in Sampran (Thailand), Cebu (Philippines), Matsumoto City, and Minowa Town (Japan), targeting older adults and working-age populations. A total of 481 participants were assessed using anthropometric measurements, blood pressure, physical fitness tests (e.g., grip strength, sit-ups, balance), and cognitive function tests (reaction time and error rate via a go/no-go task device developed at Shinshu University). Physical activity was measured using pedometers to track daily steps.\u003c/p\u003e\u003cp\u003eSignificant improvements were observed in weight, BMI, muscular strength, balance, and executive function across several sites. In Minowa Town, where participants averaged 73 years in age, the average daily step count was 8,701. This finding suggests that sustained behavioral change may be linked not merely to step targets, but to internalized understanding of the health benefits of physical activity. While more than 7,000 steps per day is generally considered beneficial, our results indicate that age, motivation, and social context may moderate these outcomes.\u003c/p\u003e\u003cp\u003eThese findings underscore the importance of age- and context-appropriate interventions that integrate both physical and cognitive health components. This study also highlights the value of culturally adaptable health education strategies when addressing diverse populations across national boundaries.\u003c/p\u003e","manuscriptTitle":"Health education interventions across Thailand, the Philippines, and Japan: A multisite comparison in varying socio-environmental and policy contexts","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 02:13:59","doi":"10.21203/rs.3.rs-7027881/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-08T05:57:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-01T01:18:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-24T12:46:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325329073224783604463210249310217028629","date":"2025-08-18T22:47:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175102920758187652070899508592012808569","date":"2025-07-18T13:04:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-17T19:15:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-09T08:10:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-09T07:40:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-09T07:40:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-07-02T09:40:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be27945f-8dae-4c91-a5e1-bbf3278006c9","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:12:33+00:00","versionOfRecord":{"articleIdentity":"rs-7027881","link":"https://doi.org/10.1186/s12889-025-25496-w","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-11-22 15:57:55","publishedOnDateReadable":"November 22nd, 2025"},"versionCreatedAt":"2025-07-23 02:13:59","video":"","vorDoi":"10.1186/s12889-025-25496-w","vorDoiUrl":"https://doi.org/10.1186/s12889-025-25496-w","workflowStages":[]},"version":"v1","identity":"rs-7027881","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7027881","identity":"rs-7027881","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}