Municipal implementation of community-based preventive programs during the COVID-19 pandemic and long-term care certification trends in Japan: a nationwide ecological analysis

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BACKGROUND: The coronavirus disease (COVID-19) pandemic disrupted community-based preventive services for older adults. However, population-level evidence linking municipal implementation of such services during the pandemic to subsequent care-need outcomes remains limited. Japan's long-term care insurance (LTCI) system, in which municipalities administer preventive programs and care-need certification is conducted through a standardized process, provides an appropriate setting for examining this association. This study examined whether municipal implementation status of preventive programs planned for FY2020 was associated with subsequent trends in LTCI certification rates. METHODS: We conducted a nationwide ecological analysis linking a municipal survey conducted in 2021 to annual LTCI certification rates for FY2018-2023. The exposure was full versus incomplete implementation of programs planned for FY2020 across five prevention domains: physical activity, social participation, cognitive training, nutrition, and health check-ups. Collapsed difference-in-differences models compared changes in certification rates from the pre-pandemic period (FY2018-2019) to the pandemic (FY2020-2021) and post-pandemic (FY2022-2023) periods. Event-study models estimated year-specific differences in certification-rate changes. Models were adjusted for baseline LTCI certification rate, aging rate, log-transformed population size, and fiscal capacity index. Sensitivity analyses assessed additional contextual adjustment, exclusion of municipalities without planned programs, alternative LTCI certification outcomes, and potential nonresponse bias. RESULTS: Of 1,741 municipalities invited, 1,114 were included in the primary analysis. Full implementation was reported by 174 municipalities (15.6%) for physical activity and 158 (14.2%) for cognitive training. Full implementation of physical activity programs was associated with smaller increases in LTCI certification rates during the pandemic period compared with incomplete implementation (-0.12% points [pp], 95% confidence intervals [CI]: -0.23 to -0.01). A comparable association was observed for cognitive training (-0.14 pp, 95%CI: -0.25 to -0.03). Sensitivity analyses generally showed similar directional patterns, although estimates were modest and less precise when additional contextual adjustment was applied, municipalities without planned programs were excluded, or alternative certification thresholds were used. CONCLUSIONS: In this nationwide ecological analysis, full implementation of physical activity and cognitive training programs planned for FY2020 was associated with smaller subsequent increases in municipal LTCI certification rates. These findings suggest that municipal implementation status during the COVID-19 pandemic may be related to population-level care-need trends. However, causal interpretation is limited by the ecological design, single-time assessment of implementation status, potential exposure misclassification, and possible pandemic-related changes in LTCI certification procedures.

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