Rice farming care as a novel method of green care farm in East Asian context: an implementation research

A new type of dementia care that is offered on a farm setting, green care farms (GCFs), is emerging from the Netherlands [1]. GCFs programs are an empowerment-oriented, strengths-based, community-based service that aims to improve the quality of life of people with dementia (PWD) [2]. Previous research on residents living on GCFs reported that, compared to usual care, quality of life (QOL) was higher, especially in the areas of positive effect, social relationships, and having something to do [3]; furthermore, caregivers working in GCFs were more positive about the physical environment, activities, and person-centered care [4].

Identifying the most beneficial activities for PWD has been a priority in dementia research, especially given the challenge of aging societies, whereby people worldwide are generally living longer, thus increasing the incidence of dementia. According to Harmer [5], PWD, staff, and carers have different views about what makes activities meaningful; staff and family caregivers consider activities that maintain physical well-being meaningful, whereas PWD find meaning in activities that address their psychological and social needs. According to De Bruins [6], farm activities fit within normal daily life and are considerably different from traditional nursing home activities, which often have an institutional character (e.g., memory training and bingo). In addition, according to Moyle [7], the factors associated with a positive QOL were relationships with family members and other people, the need for control over their lives, and, more importantly, the need to contribute to their communities. According to a qualitative analysis of in-depth interviews with PWD, a key factor in preserving personal dignity is engagement in meaningful activities within the safe and secure environment of the patient’s home [8].

To enable PWD in Japan to perform meaningful activities, we developed the only vernacular GCFs in Japan, which is called rice farming care (RFC) [9‐12]. This project began in 2016 and was made available to PWD who visit the day-care center located in the psychiatric hospital, as well as to PWD living in the nearby group home. Historically, people living in psychiatric hospitals and their related institutions are sometimes secluded from their fellow patients, families, friends, and visitors [13]. However, since the launch of this project, we have observed that various people, i.e., family members, volunteers, researchers, and city officers, more frequently visit the hospital and that patient–patient, staff-staff, and patient-staff communication has improved. Thus, while the RFC might have an inclusive effect for otherwise excluded people, the mechanism underlying this effect has not yet been explored. As described elsewhere [10], rice farming has special cultural importance in Japan. For example, rice wine is offered to deities during Japanese rituals; rice plays a crucial role in communal activities, in that to eat rice from the same pan represents strong friendship within a person’s social group; the “land of abundant rice” is often used as a poetic name of ancient Japan; and finally, the emperor himself plants and harvests rice [14]. Rice farming might therefore be a meaningful activity for PWD who can no longer participate in society as before.

The aim of this study was to 1) implement GCFs which use rice farming in Japan, which is common in East Asian environments; 2) explore the positive experiences of PWD who completed the RFC program (qualitative measures); and 3) compare the effect of RFC with that of usual care for well-being and cognitive ability (quantitative measures).

We used a realist approach to develop and assess how interventions work in particular contexts to inform future implementation of RFC in real-world environments. We recruited people who visit the day-care center in our hospital and people who live in the group homes next to the hospital. In detail, recruitment was done in outpatient clinic; only those who responded positively to our recruitment participated to our study. Participants were receiving standard care in the day-care center or group homes; we did not replace this care, but offered them additional, year-round, once-a-week, 90-min sessions.

In this setting, randomization was not considered appropriate, i.e. dividing those who wanted to participate into intervention group and control group was not feasible from a realistic viewpoint. At the same time, as an implementation research, to show its effect by comparison was necessary for the future study. Accordingly, we decided to obtain the reference data.

The reference group were recruited in the day-care program or in the group home for PWD, which have been collaborating with our hospital. Reference group’s day-care center or group home was about 30 min’ ride by car, which means that they were not able to participate to our current activity. But, in case our activity expands to other setting, they would be the potential candidates. We adopted a convergent parallel mixed methods design. We collected both quantitative and qualitative data from those who participated in the RFC program. In addition, we collected quantitative data from the reference group. This study was conducted in Niigata prefecture, Japan. The authors confirm that all ongoing and related trials for this intervention are registered.

In this study, we implemented RFC, a newly emerging method that is an empowerment-oriented, strengths-based, and community-based service that aims to improve the QOL in PWD, in a Japanese and East Asian context. We found that well-being of the RCF group was recovered by the intervention, and that RFC group was reported to exert a favorable change on all participants. The main activity of this intervention was rice farming, which is a major aspect of Asian agriculture; our intervention method could therefore be applied in other East Asian countries.

The most important finding of this study was that the intervention was meaningful for PWD. According to Phinney [20], the activities of PWD become meaningful through feelings of pleasure and involvement, a sense of connection and belonging, and a sense of autonomy and self-identity. Indeed, the participants in this study reported feelings of pleasure and involvement and a sense of connection and belonging. Although PWD did not directly mention having a sense of autonomy and self-identity, the staff interviews indicated that RFC increased patients’ sense of autonomy and self-identity; the family of one participant rediscovered his identity through seeing him take part in activities that were similar to his previous work as a farmer, and one staff member rediscovered the strength and pride of PWD.

On the other hand, the green care farm group had more males and more persons previously engaged in rice farming. Therefore, the favorable result may due to returning to familiar and meaningful work for them. Cautious interpretation is essential.

From a clinical standpoint, one of the great changes was that this project shook the old culture of the hospital staff. Given that an impairment in orientation to time is a common symptom of dementia, hospital staff often ask PWD about the date and day of the week to assess cognitive ability. In this project, we often told patients that knowing the date or day of the week did not matter on the farm, and only the season was important. Similarly, dementia is often associated with a decline in instrumental activity of daily living; participants were told that if they could not use the ATM, community living can indeed become more difficult, but this would not impede their farming activity during the intervention. This project was based around person-centered care, whereby PWD are regarded as individuals with unique identities rather than people defined by their symptoms [21, 22].

GCFs has some merits for the rapidly aging societies in which we live; especially given that the number of younger people is simultaneously decreasing. These advantages are as follows: 1) GCFs does not require the construction of new facilities because farms are already there; 2) older farmers can be hired as staff to help with the agricultural processes; 3) GCFs makes use of fallow land effectively. We are planning to use the products in the lunch of a nearby elementary school, which would enhance inter-generation communication.

This study has several limitations. First, it was conducted in only one area in Japan and the number of participants was small. A confirmation study at multiple sites would therefore be necessary for generalization of the results. Second, we did not record the audio or produce verbatim transcriptions in our qualitative analysis. Additionally, the vocabulary of PWD was limited, and so video recordings and visual analysis might help to overcome this limitation. Third, we could not control the activity of the reference group, such as frequency, intensity, and length. This was beyond our capacity. Forth, intervention group and reference group might not be homogeneous, meaning that selection bias is inevitable; the intervention group had more males and more persons previously engaged in rice farming.

Green care farms by using rice farming is promising care method which is evidence-based, empowerment-oriented, strengths-based, community-based dementia service, which also delivers meaningful experience for the people with dementia in East Asia. Although it might be a challenge in a real world setting, further research using the more empirical methodology such as randomization is necessary for the further implementation.