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Using women-only fitness club and functional disability: a cross-sectional study using propensity score matching

Archives of Public Health volume 83, Article number: 114 (2025) Cite this article

Abstract

Background

As the aging population grows, identifying effective interventions to achieve healthy ageing is crucial. Specific environments, such as Curves, the women-only fitness club (WOFC), may provide a supportive setting for older women to engage in physical activities that promote overall healthy ageing. This study aims to compare the functional disability prediction score between WOFC members and control group in older adults.

Methods

Our study design was cross-sectional design. We applied propensity score matching to control for 9 potential confounders, including age, sociodemographic factors, health-related factors. A total of 6,058 participants were matched (3,029 WOFC memberships and 3,029 control groups from the Japan Gerontological Evaluation Study). The functional disability prediction scores we used can predict the risk of functional disability within three years for community-dwelling older adults without activity of daily living limitations.

Results

After propensity score matching, the covariates of the two groups were well balanced. The average age after propensity score matching was 72.4 for WOFC members and 72.7 for the control group. The average functional disability prediction score was 0.53 points lower for WOFC members than for the control group (p =.005).

Conclusions

WOFC members had lower scores on the functional disability prediction score related to healthy aging. Future studies should investigate the long-term impact of such programs.

Peer Review reports

Text box 1. Contributions to the literature

• Physical inactivity among older adults is a pressing issue in promoting healthy ageing and is particularly prevalent among women than among men.

• The availability of fitness and sports facilities is a key factor in promoting physical activity among older adults.

• This study compared the functional disability prediction scores between Curves, the women-only fitness club (WOFC) members and control group in older adults.

• The average functional disability prediction score was 0.54 points lower for WOFC members than for the control group (p =.005).

• WOFC may serve as an effective intervention to achieve healthy ageing.

Background

Physical inactivity among older adults is a pressing issue in promoting healthy ageing [1]. Physical inactivity is a major cause of non-communicable diseases, premature mortality and economic burden [1,2,3]. The 2020 World Health Organization guidelines on physical activity and sedentary behavior recommends regular physical exercise for all older adults [4]. Despite these important recommendations, many older adults remain physically inactive [5]. Physical inactivity is particularly prevalent among women than among men [5, 6]. Reducing physical inactivity requires concerted multi-sectoral efforts and should not exacerbate sex and age inequalities [6, 7]. As a public health policy to reduce physical inactivity, there are high expectations for creating an age-friendly environment conducive to physical activity [8, 9]. The availability of fitness and sports facilities is a key factor in promoting physical activity among older adults [10,11,12,13,14]. A systematic review of factors associated with physical activity in older adults suggests the importance of improving access to physical activity opportunities from both environmental and economic perspectives [14]. In addition to promoting physical activity, previous studies have shown that fitness and sports facilities can improve health-related quality of life [12], reduce depression [10], frailty [11], healthcare utilization, cardiovascular events and mortality [13]. Thus, creating accessible fitness and sports facilities for older adults to physical activity could be an innovative public health strategy to promote physical activity among older adults.

In Japan, the most rapidly aging country in the world, nationwide efforts have been made to promote physical activity [15]. Unfortunately, physical activity levels among older adults have been declining over the past 15 years [15], highlighting the need to enhance age-friendly facilities that support physical activity. Curves (Curves Japan Co., Ltd.) [16] is a fitness club that has the potential to create this kind of facility in Japan [17,18,19]. Curves is a women’s-only fitness club that offers 30-minute structured combined exercise program including strength training, aerobic exercises, and stretching [17]. Curve is a club where any woman of any age can easily drop in without a reservation. Curves puts the emphasis on attentive exercise coaching and friendly communication. Most Curves are located in residential and shopping areas, making them easily accessible. For women who worry that they are not good at working out or that they are losing strength as they age, or have other worries, Curves make it easy to start an exercise program and stick to it without stress or strain.

The exercise program offered at Curves, the women-only fitness club (WOFC) has been shown to help prevent type 2 diabetes [17], improve cognitive function [18], reduce chronic musculoskeletal pain, and improve activities of daily living [19]. The World Health Organization defines Healthy Ageing as maintaining a functional ability that enables individuals to meet their needs and contribute to society within their environment [7]. Based on this WHO definition, there is no evidence that using WOFC leads to healthy aging later in life. To demonstrate that WOFC contributes to healthy aging, the relationship between WOFC and functional disability, a determinant of healthy aging needs to be examined.

Therefore, our study aims to determine whether older adults can prevent the risk of functional disability by using WOFC. Our findings can provide evidence about age-friendly fitness facilities.

Methods

Study design

Our study design was a cross-sectional study. We compared the functional disability prediction score between WOFC members and a control group of older adults living in the community. We extracted the control group from the Japan Gerontological Evaluation Study (JAGES) using propensity score (PSM) analysis. JAGES is an ongoing national prospective cohort study that investigates the social determinants of health among people aged 65 and over in Japan [20, 21].

Study participants

Curves (WOFC) membership

We conducted a self-reported survey of WOFC membership between November and December 2023. As of August 2023, Curves supports the health and physical development of 1,962 locations and approximately 777,000 members nationwide in Japan. Of the members, about 58.0% are older adults aged 65 and over.

Figure 1 shows a detailed flowchart of participant selection. Curves mailed self-administered questionnaires to members aged 65 years and over who were not eligible to receive public long-term-care insurance (LTCI) benefits at seven locations in seven municipalities (n = 3,489; response rate: 82.6%). We excluded those without consent for study use (n = 46) and with missing age data (n = 56). We excluded those who had been members for less than a year or who used WOFC less than once a week (n = 329), with the goal of targeting older adults who habitually use WOFC. Ultimately, we included 3,058 individuals as WOFC members.

Fig. 1
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Control group

We used the JAGES data as the control group (Fig. 1). From October to December 2022, JAGES mailed self-administered questionnaires to 310,204 community-dwelling residents aged 65 years and over living in 71 municipalities (n = 208,584; response rate: 67.2%). We excluded 117,732 responses from our analysis for the following reasons: (i) ID missing (n = 2,152), (ii) study utilization disagrees and eligible to receive public LTCI benefits (n = 15,339), (iii) Men (n = 90,503), (iv) Inconsistent age and gender with registry data, and (v) activity of daily life non-independent or missing (n = 8,945). Since WOFC members were independent women in their daily lives, we applied same conditions to the control group. The control group included 90,852 individuals.

Questionnaire development

For participants in WOFC membership, we developed a paper-based survey questionnaire based on the 2022 JAGES survey questionnaire. Therefore, these questionnaires had most questions in common. These questionnaires consisted of demographic characteristics, physical and psychological health, and social factors. For WOFC membership questionnaire only, we asked about subjective changes in physical, psychological, and social aspects after joining WOFC (Supplementary Table 1).

Outcome variables

Our outcome variable was the functional disability prediction score (Supplementary Table 2) [22, 23]. This score, consisting of sex, age, and 10 essential items from the Needs Survey, was developed to predict the risk of LTCI certification within three years for community-dwelling older adults without activity of daily life limitations [22, 23]. The Needs survey, conducted every three years by municipality, aims to formulate the LTCI plan based on a model provided by the Ministry of Health, Labor and Welfare [24]. These 10 essential items are derived from parts of the “Kihon Checklist” [25, 26] and “Tokyo Metropolitan Institute of Gerontology Index of Competence” [27], which mainly evaluate functional disability and higher-level functional capacity in older adults. This score ranges from 0 to 48, and the higher the score, the greater the risk of functional disability [22, 23]. In addition, this score can estimate subsequent cumulative LTCI cost [28].

Covariates

We selected 9 potential confounders from common question items between the two questionnaires that were hypothesized to be associated with functional disability [29, 30]. Sociodemographic factors included age (continuous), educational attainment (≥ 13 years, 10–12 years, and < 9 years), annual equivalized income (continuous), marital status (married and single/ other), living alone (yes, or no), frequency of participation in income-generating activities (none, once a week or less, two or three times a week, and four or more times a week) and population density. We classified the municipalities into the following three categories according to the calculated population density of habitable land: metropolitan (≥ 4000 people/km2), urban (1000–3999 people/km2), and rural (< 1000 people/km2) [31, 32]. Health-related factors included self-reported illness, frequency of going out (At least once a week, and less than once a week), daily walking time (more than 60 min, and less than 60 min) [33], and social participation (sports groups and clubs, hobby groups) [34, 35]. Frequent outings, long walking times [33], participation in sports or hobby groups [34, 35] have been reported to be associated with lower cumulative long-term care benefit costs. We assessed self-reported medical conditions with yes or no answers and included hypertension, stroke, heart diseases, diabetes mellitus, musculoskeletal disorders, and cancer. We assumed that frequency of going out, daily walking time, and social participation would change after joining WOFC. Therefore, we asked WOFC members about frequency of going out, daily walking time, and social participation before joining WOFC. Social participation was defined as participation in sports groups, clubs, or hobby groups, and was categorized as participating at least once a month or less than once a month.

Propensity score matching of control participants to WOFC memberships

We conducted PSM analysis to compare the functional disability prediction score between the WOFC memberships and control groups. We estimated propensity scores using a logistic regression model with the 9 covariates listed above. We performed 1:1 caliper matching with replacement using the nearest neighbor matching method. We determined the caliper width to be equal to 0.2 of the standard deviation of the logit of the propensity score. To assess the covariate balance after matching, we calculated the absolute standardized differences between the two groups. An absolute standardized difference of less than 10% is an indication of a good balance between the covariates [36].

Statistical analysis

After PSM, we used the paired t-test to evaluate group differences in the functional disability prediction score between WOFC members and control groups.

We also conducted four additional analyses. In the two additional analyses, we changed the definition of WOFC members to eliminate the possibility of differences results due to differences definition of participants. We conducted additional analyses to confirm that our results were consistent even among frailer WOFC members. First, we limited WOFC memberships to those with the functional disability prediction score of 17 points or more. The risk of developing functional disability increases for older people with a functional disability prediction score of 17 points or more (the sensitivity and specificity were both 0.733) [22]. Next, we analyzed all valid respondents to WOFC membership survey. This analysis also included older adults who had a short membership period or used WOFC infrequently. In the third additional analysis, to explore the factors that affect the functional disability prediction score, each of the 10 items in the functional disability prediction scores, excluding age, was compared. Finally, we used only the data from WOFC membership questionnaire survey. We examined whether long-term WOFC members experienced positive physical, psychological and social changes after joining, compared to members who had shorter memberships. The outcome variable is the subjective change in the 12 items after joining the exercise facility, as listed below: (1) Places to go out, (2) Walking opportunities, (3) Area of activity, (4) Enjoyment in everyday life, (5) Opportunities to feel “Ikigai”, (6) Opportunities to laugh, (7) Opportunities to feel cheerful, (8) Opportunities to talk with family, (9) Opportunities to talk with people outside of your family, (10) Opportunities to support each other, (11) Opportunities to participate in community activities, and (12) Opportunities to eat with others (Supplementary Table 1). We defined (1) to (3) as physical aspects, (4) to (7) as psychological aspects, and (10) to (12) as social aspects. We conducted a modified Poisson analysis with robust standard errors [37] to estimate the prevalence ratios of the association between the duration of WOFC membership and positive subjective changes. This analysis served as a reference for understanding the relationship between WOFC members and healthy ageing.

These statistical analyses used Stata 17/IC (StataCorp, College Station, TX, USA). We addressed the issue of multiple testing using the Bonferroni correction and set a more conservative p-value cutoff. The comparison of the functional disability prediction scores between WOFC members and the control group was set at p =.0166 (0.05/3), and the comparison of the 10 items of the functional impairment prediction score was set at p =.0050 (0.05/10). Similarly, the additional analysis of the WOFC members only was set at p =.0041 (0.05/12).

Missing data

Missing values across variables ranged from 0% (age) to 15.3% (income). Missing values were imputed using random forest imputation, an iterative imputation method based on random forests that creates multiple imputation schemes by averaging many unpruned classification or regression trees [38]. We used R, version 4.2.1, and the missForest packages for this analysis.

Results

Table 1 shows the characteristics of WOFC memberships and control participants. As a result of conducting PSM analysis at a 1:1 ratio, we obtained 3,029 participants in each group. We show the differences in characteristics between the two groups before and after PSM in Tables 1 and 2, respectively. The absolute standardized difference values for all variables were less than 0.10 (Table 2). This finding indicates that the covariates of the two groups were well balanced.

Table 1 Characteristics of WOFC members and control groups before propensity score matching
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Table 2 Characteristics of WOFC members and control groups after propensity score matching
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Table 3 shows comparisons of the average functional disability prediction scores for WOFC members and the control group. The average functional disability prediction score was 0.5 points lower for WOFC members than for the control group (p =.007). We conducted two additional analyses with the definition of WOFC membership changed. In all analyses, WOFC members had lower functional disability prediction scores than the control group. After Bonferroni correction, the additional analysis for all WOFC members exceeded the threshold of p =.05. Supplementary Table 3 shows a comparison of the 10 items of the functional disability prediction score, excluding the ages of the WOFC members and the control group. Of the 10 items in the functional disability prediction score, fewer WOFC members had a BMI of 18.5 or less than the control group, and fewer members had reduced the frequency of their outings compared to a year ago. After Bonferroni correction, these associations remained below the p =.05 threshold. After Bonferroni correction, the p-value exceeded the threshold of p =.05, but compared to the control group, WOFC members had a higher ability to go out using trains and buses.

Table 3 Comparison of the functional disability prediction score between WOFC members and control groups after propensity score matching
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Table 4 shows the relationship between the association between the duration of WOFC membership and the 12 positive subjective changes after joining. Members with more than three years membership were more likely to feel that they had more opportunities to laugh and talk with people other than their family after joining than members with less than one year of membership. After Bonferroni correction, these associations remained below the p =.05 threshold. Compared with WOFC members with less than one year, WOFC members with more than three years were moderately associated with many opportunities to walk, support each other, participate in community activities, and eat with others. These associations were above the threshold of p =.05 after Bonferroni correction.

Table 4 The prevalence ratios of the association between the duration of WOFC membership and positive subjective changes
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Discussion

Main findings

To the best of our knowledge, this has been the first study to investigate functional disability prediction scores in WOFC offering the structured 30-minute exercise program. There are two main findings. First, WOFC members had lower functional disability prediction scores compared to the control group of community-dwelling older adults. This result was consistent even when the definition of WOFC members was limited to frail people. Specifically, fewer WOFC members had a BMI of 18.5 or less than the control group, and fewer members had reduced the frequency of their outings compared to a year ago. Second, additional analysis limited to WOFC members revealed that those with longer membership experienced positive psychosocial changes in daily life.

The mechanisms that WOFC contributes to healthy aging

Although our study design was cross-sectional, our findings suggest that WOFC, a private fitness club, could potentially contribute to healthy ageing in community-dwelling older adults. In the additional analysis, fewer WOFC members had low BMIs and went out less often than the controls. A low BMI and low frequency of physical activity are factors that are detrimental to healthy aging [23, 26]. The availability of fitness facilities promotes physical activity [14], improves physical and mental health [10, 12], and helps reduce health care costs [11] for older adults. In this study, we found that even among older and higher-risk populations, the fitness facility members had lower functional disability scores compared to control group. The structured programs provided at WOFC align with WHO’s recommended multi-component exercises [4], and previous short-term follow-up studies have shown positive associations with various health outcomes [17,18,19]. The reason why WOFC members had lower functional disability prediction scores than the control group may be because this evidence-based program is delivered under expert guidance. Furthermore, the fact that the program was easy for even older women who were apprehensive about exercise to participate in may explain its effectiveness in reaching a broad demographic. In the future, longitudinal studies using control groups will be necessary.

Psychological benefits in WOFC

The positive psychosocial changes observed in long-term members may offer insights into the mechanisms through which WOFC contributes to healthy ageing. Interestingly, we found these changes more pronounced in psychosocial than physical aspects. More specifically, the longer a person has been a member, the more they feel that they have had more opportunities to laugh and talk with people other than their family. Laughing with others, especially friends, has been shown to contribute to healthy aging [39]. This may be due to staff-member and member communication as well as social interactions at WOFC. Perhaps the friendly communication that takes place in a space for women only promotes social interaction. In Japan’s key healthy aging initiative, “Community Gathering Place [40, 41],” something similar has been observed [42]. Community gathering places function as focal points for local older adults to engage in health-promotion activities, which include both physical and cognitive exercises, as well as artistic, educational, and social activities [42, 43]. Previous studies has shown that participation in community gathering places fosters subsequent social interaction [42, 44]. WOFC may also function as similar community gathering places, fostering social interaction among memberships. While further verification of multiple facilities is needed, age-friendly fitness facilities may strive to promote laughter and interaction among participants in addition to evidence-based exercise programs.

The value of investing in fitness facilities

Our study has the potential to inform policy makers about the value of investment in private fitness facilities for healthy ageing. Innovative strategies at the population level are needed to address physical inactivity and promote healthy ageing [7]. While our study was cross-sectional and should be interpreted with caution, future longitudinal studies that track both facility members and non-members can contribute to the growing evidence on fitness facilities and healthy ageing. The functional disability prediction score used in this study can also estimate cumulative LTCI cost (6 years of cumulative LTCI costs of 31.6 thousand yen per point) [28]. Using the results of the main analysis, the cumulative reduction LTCI cost for 1,000 WOFC members over a six-year period is calculated as 31.6-thousand-yen x 0.54 points x 1,000 people = 16,748 thousand yen. Our results suggest that there is considerable potential for curbing the cumulative LTCI costs of WOFC members. Further studies could facilitate the introduction of pay-for-success financing models [45, 46], encouraging private investors to support fitness facilities development as a preventive healthcare intervention. The kind of monetary estimates produced by this study may help to inform the decision-making of policy makers and private investors.

Limitations

Our study has some limitations. First, our study design was cross-sectional, we cannot rule out reverse causality, where older adults who were already more active and at lower risk of functional disability were more likely to join WOFC members. Longitudinal or experimental study is needed to address this issue. Second, there was a temporal discrepancy between the data collection years for WOFC members and the control group from JAGES—2023 for WOFC members and 2022 for JAGES. In Japan, social restrictions due to the COVID-19 pandemic were mostly lifted by 2022. We cannot deny the possibility that older adults became more active as time passed, and this may have led to an overestimation of the functional disability prediction scores among WOFC members. We have dealt with this issue as much as possible by aligning the survey months and minimizing the seasonal impact on the behavior of older adults. Third, a survival bias may exist, as many WOFC members in this study had long membership durations. However, additional analysis including those with shorter membership durations showed consistent results. Future studies should track new members and account for attrition in their analysis. Fourth, the study was limited to women due to the nature of WOFC. Nevertheless, given that women are a key population at risk for physical inactivity [47] and that limited access to fitness facilities is a barrier to continued exercise for women [48], the focus on women in this study remains valuable. Finally, this study was conducted on WOFC members, a single fitness club, so the transferability and generalizability of the results is limited. Given these limitations, more studies are needed to provide evidence that fitness clubs like WOFC contribute to healthy aging.

Conclusions

With the world’s population ageing, there is a need for innovative public health approaches to physical inactivity among older adults. Our study showed that WOFC membership, the women-only fitness club may lead to healthy ageing. Future studies are needed to examine the long-term effects of being a member of a fitness facility such as WOFC on subsequent health and well-being, as well as financial burden. These studies will help policy makers make decisions about introducing pay-for-success for fitness facilities to achieve healthy ageing.

Data availability

Availability of data and materialsThe JAGES data are available upon reasonable request at https://www.jages.net/. However, the data collected specifically for this study (the Curves data), cannot be made publicly available because the participants in this study did not consent to the public release of their data.Acknowledgements We would like to thank all participants in this study.

Abbreviations

WOFC:

Women-only fitness club

JAGES:

Japan Gerontological Evaluation Study

PSM:

Propensity score matching

LTCI:

Long-term-care insurance

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Acknowledgements

We would like to thank all participants in this study.

Funding

Curves Japan Co., Ltd funded this study. This study used data from JAGES (the Japan Gerontological Evaluation Study). This study was supported by JSPS (Japan Society for the Promotion of Science) KAKENHI Grant Number (JP15H01972, 19K20909, 20H00557, 22K13558, 25K16857 ), Health Labour Sciences Research Grant (H28-Choju-Ippan-002, 19FA1012, 19FA2001, 21GA0101, 22FA2001, 22FA1010), Japan Agency for Medical Research and Development (AMED) (JP18dk0110027, JP18ls0110002, JP18le0110009, JP20dk0110034, JP21lk0310073, JP21dk0110037), Open Innovation Platform with Enterprises, Research Institute and Academia (OPERA, JPMJOP1831) from the Japan Science and Technology (JST), a grant from Innovative Research Program on Suicide Countermeasures (1–4), a grant from Sasakawa Sports Foundation, a grant from Japan Health Promotion & Fitness Foundation, a grant from Chiba Foundation for Health Promotion & Disease Prevention, the 8020 Research Grant for fiscal 2019 from the 8020 Promotion Foundation (adopted number: 19-2-06), grants from Meiji Yasuda Life Foundation of Health and Welfare and the Research Funding for Longevity Sciences from National Center for Geriatrics and Gerontology (29–42, 30 − 22, 20 − 19, 21 − 20). This work was supported by JST RISTEX Japan Grant Number JPMJRS22B1. The views and opinions expressed in this study are those of the authors and do not necessarily reflect the official policies or positions of the respective funding organizations.

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Authors and Affiliations

  1. Center for Preventive Medical Sciences, Chiba University, Inage-ku, Chiba, Japan

    Kazushige Ide, Kenjiro Kawaguchi, Kiyomi Matsumura & Katsunori Kondo

  2. Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan

    Kiyomi Matsumura

  3. Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Minato-ku, Tokyo, Japan

    Katsunori Kondo

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  1. Kazushige Ide
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Contributions

K.I., Kenjiro Kawaguchi, and K.M. are expected to have made substantial contributions to the conception OR design of the work; OR the acquisition, analysis, OR interpretation of data; OR the creation of new software used in the work; OR have drafted the work or substantively revised itAll authors have approved the submitted version (and any substantially modified version that involves the author’s contribution to the study); All authors have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.FundingThis study used data from JAGES (the Japan Gerontological Evaluation Study). This study was supported by JSPS (Japan Society for the Promotion of Science) KAKENHI Grant Number (JP15H01972, 19K20909, 20H00557, 22K13558), Health Labour Sciences Research Grant (H28-Choju-Ippan-002, 19FA1012, 19FA2001, 21GA0101, 22FA2001, 22FA1010), Japan Agency for Medical Research and Development (AMED) (JP18dk0110027, JP18ls0110002, JP18le0110009, JP20dk0110034, JP21lk0310073, JP21dk0110037), Open Innovation Platform with Enterprises, Research Institute and Academia (OPERA, JPMJOP1831) from the Japan Science and Technology (JST), a grant from Innovative Research Program on Suicide Countermeasures (1-4), a grant from Sasakawa Sports Foundation, a grant from Japan Health Promotion & Fitness Foundation, a grant from Chiba Foundation for Health Promotion & Disease Prevention, the 8020 Research Grant for fiscal 2019 from the 8020 Promotion Foundation (adopted number: 19-2-06), grants from Meiji Yasuda Life Foundation of Health and Welfare and the Research Funding for Longevity Sciences from National Center for Geriatrics and Gerontology (29-42, 30-22, 20-19, 21-20). The views and opinions expressed in this study are those of the authors and do not necessarily reflect the official policies or positions of the respective funding organizations.

Corresponding author

Correspondence to Kazushige Ide.

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All protocols associated with our survey have received approval from the Institutional Review Board of Chiba University, with informed consent obtained from all participants.

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Ide, K., Kawaguchi, K., Matsumura, K. et al. Using women-only fitness club and functional disability: a cross-sectional study using propensity score matching. Arch Public Health 83, 114 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13690-025-01601-8

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Archives of Public Health

ISSN: 2049-3258