2025 年 3 巻 2 号 p. 58-67
Respiratory diseases are the leading cause of disaster-related deaths in Japan. Therefore, it is critical to protect older adults from pneumonia in evacuation shelters. Measures to maintain oral hygiene, support oral function and nutritional status, and reduce the risk of aspiration pneumonia require multidisciplinary support. This study examined the support systems for oral health and nutritional care following the 2024 Noto Peninsula Earthquake, which occurred on January 1, 2024. We explored the experiences and perceptions of healthcare professionals who provided oral health and nutritional care within approximately two months after the disaster by using questionnaires and qualitative interviews. Qualitative analysis showed that there are six key themes regarding the challenges and support associated with oral health and nutrition: 1) logistics and distribution, 2) lack of human resources, 3) coordination and handover, 4) nutritional status and support, 5) oral status and support, and 6) knowledge of support personnel. These findings indicate that oral and nutritional care are critical for pneumonia prevention in disaster-affected areas. Early intervention and nutritional support are particularly important for older adults in evacuation centers. Therefore, a multidisciplinary approach for oral and nutritional support is essential.
In recent years, Japan has experienced several large-scale natural disasters, and the probability of the country being hit by an earthquake with seismic intensity ≥6 in the next 30 years is considered very high1). Respiratory infections are common after natural disasters, particularly in displaced individuals, older adults, and young children2,3). The increase in respiratory diseases may be related to the large older adult population in tsunami-affected areas4,5). In Japan, respiratory diseases are as common as cardiovascular diseases in disaster-related deaths6).
Care for older adult evacuees is particularly important because they may not report problems7). Among those who complained of respiratory symptoms, survivors in evacuation centers had an increased incidence of acute respiratory infections (ARIs)8). The number of ARIs detected in affected areas after an earthquake was higher than that in neighboring regions unaffected by the earthquake, where most survivors live in shelters9,10). Oral care has been reported to reduce the risk of aspiration pneumonia and helps maintain the nutritional status of frail older adults11–13). Older adults and infants are most likely to have difficulty eating at evacuation centers14). As the evacuation period increases, the number of older adults receiving care from dietitians will also increase15). Chewing and swallowing difficulties are associated with weight loss and malnutrition16), and improved eating and swallowing status lead to better nutritional outcomes17). Measures to maintain oral hygiene, oral function, and nutritional status and reduce the risk of aspiration pneumonia require specialized knowledge of oral health and nutrition as well as support from the dental profession and a multidisciplinary team18). The need for comprehensive feeding support from oral health to nutrition has been reported during disasters19). However, there are few reports on the systems and activities supporting them.
Therefore, we investigated the support activity for oral health and nutritional care during the 2024 Noto Peninsula Earthquake (magnitude 7.6) on January 1, 2024, from its occurrence until two months after the earthquake. The purpose of this qualitative study was to clarify the structure, roles, and challenges of oral and nutritional care systems implemented in response to the 2024 Noto Peninsula Earthquake, with particular attention to multidisciplinary collaboration and community-based support for older adults. Furthermore, this study examined the establishment of a support system for oral health and nutritional care to prevent disaster-related deaths due to pneumonia, poor nutrition, and inactivity. By analyzing post-disaster practices, this study aims to provide insights into effective health support systems for vulnerable populations and contribute to future disaster preparedness and reduction of disaster-related health risks.
This study employed a questionnaire survey, and interviews were conducted to identify the multidisciplinary elements involved in oral and nutritional care during a disaster response.
Questionnaire survey: A qualitative questionnaire was distributed online by using Google Forms to healthcare professionals with prior disaster relief experience. The survey was conducted over 10 days beginning on March 6, 2024. Participation was voluntary, and informed consent, anonymity assurance, and contact information were obtained. The survey aimed to explore the needs, challenges, and perspectives of oral and nutritional care during the initial two months following an earthquake.
Interviews: Interviews were conducted with four speech–language–hearing therapists and four dietitians who actively participated in relief efforts. The interviews sought to capture their roles, inter-professional collaborative experiences, and insights into their oral health and nutritional support. Participants were grouped by profession for focused discussions conducted between November and December 2024.
Data collectionSurvey items included demographic information (age and qualifications), experience in disaster relief, adaptation to cold weather, means of transportation, timing of support, area of deployment, accommodation methods, and group affiliations. Respondents were also asked about their needs in evacuation shelters, access to supplies, and methods and content of oral and nutritional care. Open-ended questions addressed challenges and opinions regarding care implementation.
Data analysisAfter the response period ended, the survey data were summarized for the selection response. For the descriptive sections of the questionnaire and interview data, the first author repeatedly read the transcripts to become acquainted with the data and performed data cleansing to improve readability. This process involved clarifying meanings to enhance readability, converting fragmented comments into full sentences, and expanding abbreviations and acronyms. The qualitative data were then analyzed by inductive manual coding through a qualitative content analysis approach20). Emphasis was placed on the objectivity and reproducibility of the results via content analysis. The first author labeled the data by segmenting and condensing them into individual sentences. Emergent labels were organized through group discussions among all authors. The grouping process involves reading and comparing individual labels to cluster similar labels into categories and inductively formulate themes. Qualitative data from the individual response period were shared with all authors, except the first author, to collect additional input by adding new terms or feedback. The first author conducted the analysis, and all authors reviewed and validated the results.
Ethical approvalFor the questionnaire survey, the purpose of the study was explained in writing, and consent was obtained. For the interview survey, the purpose of the study was explained verbally and in writing, and the participants’ consent was obtained. Web conferences were conducted using passcodes and security measures. To protect personal information, the data provided were not personally identifiable. This study was approved by the Ethics Committee of Hamamatsu University School of Medicine and followed the “Ethical Guidelines for Life Science and Medical Research Involving Human Subjects” (No. 24-120, July 30, 2024).
This study surveyed 25 professionals who were involved in providing oral and nutritional care in evacuation centers and welfare shelters after the 2024 Noto Peninsula Earthquake. The respondents were dentists (n = 5), nurses (n = 7), dental hygienists (n = 5), speech pathologists (n = 3), dietitians (n = 2), and others (n = 3), and most of them were in their 50s (n = 11) and 60s (n = 7) (Table 1). Thirteen (52%) had experience in disaster relief, and 17 (68%) had experience in cold weather relief.
| Characteristic | Category | All target audience (n = 25) |
|---|---|---|
| Affiliation | Hospitals | 3 |
| Medical clinic | 1 | |
| Dental clinic | 10 | |
| Institutional, daycare, and visiting services | 5 | |
| Educational institutions | 1 | |
| Freelance | 4 | |
| Group employee | 2 | |
| Age | 30s | 2 |
| 40s | 5 | |
| 50s | 11 | |
| 60s | 7 | |
| Occupation | Dentist | 5 |
| Nurse | 7 | |
| Dental hygienist | 5 | |
| Speech–language–hearing therapists | 3 | |
| Nutritionist | 2 | |
| Care worker | 1 | |
| Care support specialist | 1 | |
| Office worker | 1 | |
| Disaster relief experience | Yes | 13 |
| No | 12 | |
| Cold weather experience | Yes | 17 |
| No | 8 | |
| Accommodation environment* | Hotel | 11 |
| Overnight in a car, shelter office, among others | 18 | |
| Day trip | 1 | |
| Affiliation | Private organization | 18 |
| Public organization | 7 | |
| Difficulty in a cold climate | Vehicle equipment and driving | 9 |
| Meals and living | 5 | |
| Equipment | 5 | |
| None | 11 | |
| Place of support* | Designated shelter | 14 |
| Welfare shelters | 23 | |
| A welfare shelter not yet established | 1 | |
| Period of support activities* | Hyper-acute | 1 |
| Acute | 7 | |
| Subacute phase | 13 | |
| Chronic phase | 18 |
*Participants engaged in two or more service activities and long-term service activities provided multiple responses.
The most common type of assistance was from social shelters (23 cases), followed by designated shelters (14 cases) (Table 1). Duration of assistance was concentrated in the chronic and subacute phases.
According to relief workers, the most common intervention needed by evacuees was oral care, followed by dental treatment and dietary adjustment (Table 2). In terms of the actual support provided, designated evacuation centers focused on oral health screening and oral care, whereas welfare evacuation centers provided oral care and oral hygiene education. Regarding perceived needs by profession (Table 3), nurses paid particular attention to oral care and dietary patterns, whereas dentists paid particular attention to oral care.
| Category | Type of support provided | n |
|---|---|---|
| Support needed | Oral care | 22 |
| Dental care | 13 | |
| Oral hygiene instruction | 9 | |
| Dietary pattern | 13 | |
| Nutritional guidance | 6 | |
| Swallowing evaluation training | 3 | |
| Support provided at designated evacuation centers | Intraoral visual examination | 13 |
| Oral care | 11 | |
| Oral hygiene instruction | 8 | |
| Oral function training instruction | 4 | |
| Dental treatment | 3 | |
| Eating and swallowing evaluation and training | 4 | |
| Adjustment of eating patterns | 6 | |
| Nutritional guidance | 2 | |
| Others | 2 | |
| Support provided at welfare shelters | Intraoral examination | 11 |
| Oral care | 18 | |
| Oral hygiene instruction | 13 | |
| Oral functional training guidance | 7 | |
| Dental treatment | 4 | |
| Eating and swallowing evaluation and training | 4 | |
| Adjustment of eating patterns | 10 | |
| Nutritional guidance | 5 | |
| Others | 4 |
| Occupation | Type of support needed | |||||
|---|---|---|---|---|---|---|
| Oral care | Dental treatment | Oral health | Dietary pattern | Nutritional guidance | Swallowing function evaluation training | |
| Dentist | 5 | 2 | 2 | 2 | 1 | 0 |
| Nurse | 7 | 4 | 3 | 5 | 1 | 1 |
| Dental hygienist | 2 | 2 | 0 | 1 | 1 | 1 |
| Speech–language–hearing therapists | 4 | 3 | 4 | 2 | 1 | 1 |
| Nutritionist | 1 | 1 | 0 | 2 | 1 | 3 |
| Other | 3 | 1 | 1 | 2 | 1 | 0 |
Qualitative analysis revealed various issues and support related to oral and nutritional care during disasters (Tables 4–7).
| Category | Code |
|---|---|
| Oral condition | Many evacuees experienced deterioration of oral hygiene. |
| Ill-fitting dentures due to weight loss were common. | |
| Dentures were severely contaminated due to lack of cleaning. | |
| Some evacuees only rinsed without brushing because of water shortage. | |
| Lack of experience with oral care under limited water conditions caused confusion. | |
| Knowledge of supporters | Many relief worker lacked knowledge of a little water oral care methods. |
| Care was inadequately provided because of insufficient knowledge. |
| Category | Code |
|---|---|
| Distribution and logistics | Dysphagia diets and supplements were not properly delivered to shelters. |
| Supporters and municipal staff lacked adequate nutritional knowledge. | |
| Created procurement lists for supplements and texture-modified foods. | |
| Food should be stockpiled with consideration to texture and dietary needs. | |
| High-calorie supplements and drinks were considered beneficial. | |
| Standard emergency food was often inadequate for elderly needs. | |
| Maintaining health with limited preserved food was challenging. | |
| Nutritional status | Shortages of vegetables and fruits were observed. |
| Some older adults had reduced appetite. | |
| Preserved food was often salty and low in vegetables and protein. | |
| Food texture modification | Soft meals were provided, and food textures were adjusted using relief supplies. |
| Assessments and advice were provided regarding food textures that are suitable for chewing and swallowing. | |
| Nutritional assessment | Missing food items were provided, and meals were adjusted for protein and vegetables. |
| Meal contents and nutritional needs were assessed in shelters. | |
| The swallowing function and nutritional status of older evacuees were evaluated. |
| Category | Code |
|---|---|
| Collaboration | Interprofessional communication and collaboration were difficult. |
| Establishing working relationships was challenging. | |
| Coordination with official organizations was limited. | |
| Pre-established collaboration frameworks were needed before disasters. | |
| Handover | Continuity of care was hindered when staff rotated without proper handover. |
| Logistics | Few local coordinators were available for dental teams compared with medical teams. |
| It was time consuming to gather information upon arrival at disaster sites. | |
| Activity range was limited because of delayed situational understanding. | |
| Local logistic staff were insufficient. | |
| Support should not overburden local professionals. | |
| Workforce shortage | There was a shortage of healthcare personnel in disaster areas. |
| Local health professionals were also disaster victims. | |
| The number of professionals was insufficient for the number of affected people. | |
| Individualized care was often inadequate. | |
| Many evacuees refrained from asking for help. | |
| Response to evacuees | Lack of time hindered detailed care. |
| Many evacuees left shelters during the day, thus making care delivery difficult. |
| Category | Code |
|---|---|
| Oral health behavior | Initially reluctant evacuees began performing self-care. |
| Continued participation in swallowing exercises. | |
| Group life encouraged habitual oral exercises. | |
| Awareness of the importance of oral care increased. | |
| Some evacuees moved from bed to sink for oral care over time. | |
| Greater recognition of oral care importance compared to the 2011 disaster. | |
| Relief supplies | Over time, evacuees could distinguish between useful and unnecessary items. |
| Changes in evacuees | Prolonged evacuation reduced appetite. |
| Personal food preferences emerged as time passed. | |
| Regular oral care was discontinued during evacuation. | |
| Supporters’ changes | Supporters felt accepted and encouraged by evacuees. |
| Supporters experienced personal growth through their work. | |
| Positive responses from evacuees motivated care teams. | |
| Recognized the importance of emotional support, not just clinical care. |
With regard to oral healthcare, many disaster victims reported a deterioration of their oral environment, with cases of ill-fitting dentures due to emaciation and difficulties in cleaning dentures. Some were unable to brush their teeth because of water restrictions and had to resort to gargling. Caregivers also lacked knowledge about waterless oral care methods, thus making it difficult to provide adequate care (Table 4).
Nutritional care activities highlighted the lack of vegetables and proteins in diets centered around preserved foods, inadequate distribution of swallowable foods, and lack of knowledge about nutritional management. On the other hand, soft meals were provided using relief supplies, food forms were proposed according to occlusal conditions, and the dietary needs of each shelter were identified. In addition, the need for high-calorie supplemental foods and the difficulty in maintaining health due to food supply limitations were identified as challenges (Table 5).
Issues related to the support system included difficulties in coordination between professionals and public institutions as well as inadequate handovers due to changes in support staff. In addition, there is usually an insufficient number of local dental support coordinators, which delay the start of activities because of the time needed to gather information, and logistical staff is lacking. The need to avoid the overburdening of local professionals was also highlighted. In terms of human resources, the lack of professionals who can provide support makes it difficult to provide sufficient individualized support. Evacuees also reported attitudes of patience and reluctance to receive support as well as difficulties in providing support during hours when no one was available in the evacuation centers (Table 6).
In terms of changes in evacuees’ attitudes and behaviors, positive changes were observed, such as those who initially refused to provide oral care becoming more willing to do so and the continuation and habituation of swallowing exercises. Some evacuees’ attitudes and behaviors even indicated that their understanding of the importance of oral care had improved after the Great East Japan Earthquake.
Regarding psychological changes in the caregivers themselves, introspective changes were extracted through their support, such as their experience of being encouraged by the accepting attitude of the victims and their reaffirmation of the importance of listening in addition to providing professional support (Table 7).
This study qualitatively analyzed oral and nutritional care practices, their effectiveness, and the challenges faced by the elderly in evacuation centers and welfare shelters during the 2024 Noto Peninsula Earthquake. Studies have emphasized the importance of oral and nutritional care21,22). In the elderly, the deterioration of swallowing function, changes in chewing ability, and poor oral hygiene environment are closely related to the development of aspiration pneumonia21,22). The improvement of oral hygiene management in evacuation centers observed in the current study (Table 4) is consistent with the pneumonia-preventive effects of oral hygiene management reported in a study conducted after the Great East Japan Earthquake23,24). Multidisciplinary cooperation, such as by dentists, nutritionists, and rehabilitation professionals, enables the tailoring of support according to the individual needs of the elderly and contributes to the reduction in the risk of disaster-related deaths7,11,12). Therefore, multidisciplinary collaboration in disaster response is important to the provision of effective interventions.
The impact of environmental factors on health risks during disasters was also discussed. Disaster-specific factors such as dehydration, dust, and cold environments increase the risk of respiratory infections2,3), and the current study found that the modification of the environment and the restoration of oral hygiene habits contributed to health maintenance (Table 7). Furthermore, the provision of comprehensive livelihood support during disasters, i.e., “living environment–oral–nutrition” coordination, will help reduce the progression of frailty and sarcopenia25–27).
Several challenges have also emerged in conducting relief efforts. In particular, delays in supplies and personnel due to snow damage and traffic blockages have been identified as a structural constraint that is unique to the disaster area28,29). Advanced preparation and awareness raising at the community level are important to support the elderly during disasters, and advanced education and awareness-raising activities play a major role in post-disaster healthcare30,31). The current study also found that comprehensive care was difficult to provide, with many teams working independently or fragmenting care owing to a lack of common protocols (Table 6). This fragmentation reflects the importance of strengthening community-based support systems to ensure continuity of care after a disaster32). In addition, the findings suggest that even professionals with previous disaster relief experience struggle to adapt to a dynamic shelter environment where needs and resources are constantly changing.
During support activities, disaster victims began to provide oral care on their own, and relief worker recognized the importance of multidisciplinary cooperation (Table 7). Such behavior change can be used for disaster prevention education and human resource development at the local level and is expected to improve the effectiveness of disaster relief efforts33).
The Noto Peninsula region has an aging population that exceeds the national average34), and similar support needs are expected to increase in the future. Population aging is a global phenomenon35), and the results of this study provide important evidence that can be applied to international disaster responses. The strategic importance of strengthening support systems, including oral and nutritional care, in preventing disaster-related deaths is consistent with the recent focus on community-based comprehensive care systems and community resilience36,37) as well as the conclusions of studies showing the effectiveness of preventive community interventions tailored to the elderly population38). In the event of a disaster, a system in which community residents and caregivers work together to provide effective oral and nutritional care in evacuation centers can help reduce health risks.
This study has a few limitations. First, it was conducted using a survey questionnaire. Therefore, the opinions of advocates who did not respond to the questionnaire and those who did not participate in advocacy activities were unknown. Second, the results of this study cannot be generalized because of the small sample size. Further research is required to increase the sample size of this study. Third, the interviews were conducted after the earthquake in November and December 2024, which may have resulted in recollection bias.
Survey respondents included the author’s relatives and volunteer groups on the internet. Although this study focused on relief worker from private aid organizations, the results may have highlighted areas that are not covered by public support. Additional research is required to examine both public and private aid organizations.
This study identified the oral and nutritional care practices and challenges of the elderly in evacuation centers and shelters and qualitatively demonstrated the importance of multidisciplinary collaboration in disaster situations. Improved hygiene and individualized support in the shelter environments helped reduce health risks. Behavioral changes in disaster victims and learning by relief worker were also confirmed, thus suggesting that support activities can also strengthen community resilience. On the other hand, the fragmentation of support and problems in coordination were also highlighted, thus making pre-disaster preparedness and the establishment of community-based support systems an urgent issue. Future disaster response should implement a comprehensive support approach that integrates “living environment, oral health, and nutrition” as well as a strengthened collaborative system.
This study was funded by a Health Labor Sciences Research Grant (no. 22LA2003) and was supported by Urakami Foundation for Food and Food Culture Promotion.
Conceptualization, KK and TO. Methodology, KK, KN, NT-K and TO. Investigation, KK, NO, and MY.
Data curation, KK, NO. Writing — original draft preparation, K.K. Writing, reviewing, and editing: KK, KN, NT-K, TT, NU, MY, SF, and TO. Visualization, KK and KN. Supervision, KK and TO. Project administration, TO. All authors have read and agreed to the published version of the manuscript.
Informed consent was obtained from all participants
The authors have no conflicts of interest to declare.
