[Challenges, prevention, and countermeasures for social withdrawal (hikikomori) by age group].

　The term "hikikomori" was recognized by society between 1980 and 2000, when the term "NEET" also appeared and it was regarded as a problem of irresponsible youth. However, accumulation of surveys and research both in Japan and abroad, including those conducted by the Cabinet Office, has revealed that the reasons behind social withdrawal are not only limited to mental illness. There are many people who exhibit withdrawal because they are unable to establish relationships with the community and other people owing to various factors such as social systems, attachment formation, family background, and education. In other words, withdrawal is better described as a "symptom" or "condition" than a disease. Therefore, it is necessary to understand and analyze the diverse backgrounds and needs of individuals with withdrawal and confront them about their state. Currently, many hikikomori people with prolonged withdrawal are now in their 40s and 50s. With their parents' aging, there are cases where people with hikikomori and their families become socially isolated and are unable to make ends meet. It is undeniable that, until now, the society we live in as a whole has little interest in or understanding of hikikomori. In contrast, withdrawal among older adults (tojikomori), which has become a problem in the super-aging society. Tojikomori is defined as "going out less than once a week and not requiring nursing care", which is not equivalent with hikikomori. Owing to the decline in the frequency of going out among the elderly in the recent coronary crisis, the number of pre-frailty in older adults has become a nationwide problem.　Thus, both hikikomori and tojikomori are reversible conditions, and can be alleviated by providing necessary support. This paper summarizes the findings of the symposium "Challenges, Prevention, and Countermeasures for Social Withdrawal (Hikikomori) by Age Group" organized by the Committee on Mental Health and Suicide Prevention of the Japanese Society of Public Health at the 79th Annual Meeting of the Japanese Society of Public Health. This article is a compilation of findings that can benefit public health practitioners and researchers.

Prevalence of and factors related to homebound and semi-homebound older adults in a rural area in Japan.

AIM: The homebound status is associated with unhealthy factors and physical disability. However, the prevalence of those who may be at an earlier stage of the homebound status ("semi-homebound") is unclear. This study thus examines the prevalence of semi-homebound individuals and identifies the associated physical, psychological, and social factors. METHODS: A cross-sectional study invited 1,157 participants aged 65 years and more in rural Japan. The mean age was 74.7 ± 6.8. The survey questionnaire accounted for different parameters, such as age, sex, homebound status, morbidity, instrumental activities of daily living (IADL), and mental health. Ordinal regression analysis examined participants' homebound status; socio-demographic characteristics; and physical, psychological, and social variables. RESULTS: The prevalence of the homebound status was 0.11 (95%CI = 0.99-0.13), and the semi-homebound status was 0.30 (95%CI = 0.28-0.33). In the multivariable analysis, the homebound status was negatively associated with IADL (p < .001), mobility (p < .001), being alone during the day (p < .001), depression and anxiety (p < .05), and self-efficacy for going out (p < .001). DISCUSSION: The prevalence of semi-homebound individuals was approximately 30%. Homebound and semi-homebound individuals were associated with older, female, IADL, functional fitness, being alone during the day, depression and anxiety, and self-efficacy for going out. In the case of psychical, psychological, and social factors, the semi-homebound individuals revealed that these indicators fluctuated between homebound and non-homebound. Our findings further focused on semi-homebound individuals at elevated risks of disability, thereby emphasizing the need for customized intervention. Geriatr Gerontol Int 2021; 21: 1033-1039.

Factors Hindering Social Participation among Older Residents from Evacuation Zones after the Nuclear Power Plant Accident in Fukushima: The Fukushima Health Management Survey.

Considering the health effects of radiation accompanying the nuclear power plant accident that occurred in the wake of the Great East Japan Earthquake, this study aimed to examine social participation after the disaster and factors hindering participation among citizens aged ≥ 65 years from designated evacuation zones inside the Fukushima prefecture. The target population comprised 180,604 residents in 13 municipalities containing designated evacuation zones. There were 73,433 valid responses (response rate, 40.7%); of which, data from 19,573 respondents aged ≥ 65 years were analyzed. Multinomial logistic regression analyses were conducted to investigate the factors associated with social participation. In total, 53.0% of older evacuees did not participate in recreational activities or communal services. Stratified analysis showed that living outside the Fukushima prefecture and requiring assistance with activities of daily living were associated with low social participation. This study clarified that the majority of older evacuees did not participate in social activities at the time of the survey within one year of the disaster. Furthermore, where these older individuals were evacuated to and whether they were able to live independently might have affected their social participation. Better subjective health, better sleep quality, and more frequent exercise may be associated with improved social participation.

Development of a scale measuring barriers to going out among community-dwelling older adults.

AIM: To maintain the frequency of going out and to improve homebound status among older adults, specific barriers need to be identified. Hence, this study developed a scale to measure barriers to going out. METHODS: A preliminary study was carried out to collect items for the scale. We conducted semi-structured interviews with five homebound older adults, and created 14 items as a draft barrier scale. The main study included 2273 older adults and their cohabitating family members in rural Japan. For older adults, the questions included demographic characteristics, responses to the draft scale and variables to examine its validity. For family members, the questions included demographic characteristics, their relationship with the older adult and their assessment of their older relative's willingness to go out. We used data from 892 pairs for our analysis. RESULTS: We selected nine items through the criterion group strategy, and confirmed the unidimensional structure of the scale through factor analysis. The results showed significant relationships between the scale and older adults' self-efficacy about going out, their health locus of control, the frequency of going out and their reluctance to go out as assessed by family members. We carried out a receiver operating characteristic analysis to determine the scale's cut-off point. Our multivariate analysis showed that the scale had a significantly stronger association with homebound status than with other variables. CONCLUSION: We developed a highly reliable and valid scale on barriers to going out among community-dwelling older adults and confirmed its usability. Geriatr Gerontol Int 2021; 21: 238-244.

[Development of a self-efficacy scale for going out among community-dwelling elderly].

OBJECTIVES: Prevention and support for Tojikomori has been a focus of recent regional preventive efforts in reducing the need for nursing care in the elderly, requiring indicators for evaluating effects including psychological influences on the elderly. Behavior change theory suggests potential benefits of self-efficacy in outing to reduce Tojikomori elderly. However, evaluation scales for such psychological effects have hitherto been lacking. The purpose of this study was to develop a self-efficacy scale regarding going out among community-dwelling elderly (hereinafter referred to as the SEGE) and to assess its reliability and validity. METHODS: We collected survey items from 18 community-dwelling older people in A Ward, Tokyo. Based on these items, we developed a 13-item prototype scale through a preliminary survey among 258 community-dwelling elderly in O City, located in Japan. The main survey was conducted through the mail by randomly selecting 8,000 community-dwelling elderly in A Ward. The survey included the prototype scale' items and basic attributes, such as age and gender, and items from evaluation scales to be used to examine the validity of the prototype scale. RESULTS: A total of 2,627 elderly people (1,145 men and 1,482 women, average age 73.8 +/- 6.6 years) were analyzed. Of these people, 86.1% left home at least once a week. Principal component analysis revealed that the prototype scale created through the preliminary survey had a one-factor structure. Through a stepwise variable selection procedure in exploratory factor analysis, a six-item scale was developed. The alpha coefficient of internal consistency was 0.96 for these six items, confirming high reliability. Lower outing frequencies tended to be associated with lower scores of the SEGE, which correlated significantly with self-efficacy of ADL, self-rated health, and health-related quality of life (QOL), confirming criterion-related and construct validity. In addition, a confirmatory factor analysis showed that SEGE and self-efficacy of ADL, although highly correlated with each other, measured different concepts. CONCLUSIONS: A six-item and one-factor SEGE was developed with high reliability and validity confirmed. With this new indicator, we can measure the psychological effects of prevention and support approaches for Tojikomori. This scale is now expected to widely used in Japan.

[Functional status of very old people in urban area: the Itabashi Oldest-Old Study I].

It is predicted that the future increase in the oldest-old (85 years and older) population will have a marked influence on society. However, little is known about the features of various functions in the oldest-old. The purpose of this study was to clarify the functional status of the oldest-old. We surveyed all oldest-old residents in a small area of Itabashi ward in metropolitan Tokyo to clarify their living conditions. The oldest-old themselves and their family members were invited to participate, and 235 out of 311 residents (75.6%) agreed to do so. Forty-two percent of the participants were dependent and needed care from others. The ADL status measured by the Barthel Index showed that 30% of independent participants also had some deterioration of physical function. These results are indicative of increased frailty in the oldest-old. Comparison between independent and dependent (need care from others in daily living) showed that the functional status was lower in dependent group. However, the psychological well-being was the same in this two groups. These results indicate progressive functional deterioation and psychological adaptation to it, in the oldest-old. Further research to elucidate the process of psychological adaptation to frailty is necessary in order to promote the well-being among the oldest-old, in whom functional limitation is evident.

[Cognitive function among physically independent very old people in an urban community in Japan: the Itabashi Oldest-Old Study II].

This study was conducted to clarify the characteristics of cognitive function among physically independent very old people dwelling in an urban community in Japan. Five hundred and thirteen Old-Old (aged 75-84 years) and 168 Oldest-Old (aged 85-100 years) adults participated. We carried out the Mini-Mental State Examination (MMSE) for measuring cognitive functions in the elderly. Age-related differences in the total score and sub-scale scores of the MMSE were analyzed by sex using ANCOVA, controlling for education, vision and hearing problems. Mean MMSE scores for Old-Old and Oldest-Old males were 27.53 and 25.88, respectively, and those for Old-Old and Oldest-Old females were 27.77 and 24.98, respectively. Age-related differences in the MMSE total score between the Old-Old and Oldest-Old were observed in both sexes, suggesting that overall cognitive functions continue to decline over time in very old age. Age-related differences between the Old-Old and Oldest-Old in items measuring, registration, calculation and delayed recall were observed in both sexes, and in addition, time orientation, place orientation, delayed recognition, writing sentences, and copying figures were observed in females. These findings suggest that the faculties are those most sensitive to normal aging among very old individuals. There were no age group differences in five items: reverse spelling, naming objects, repeating a sentence, listening and obeying, and reading and obeying.

[Effect of a life review process to improve quality of life for the homebound elderly in Japan].

OBJECTIVE: This study examined the therapeutic effects of Life Review processes on physical and psychological functions of homebound elderly in Japan. METHODS: From 1998, a cohort of people aged 65 and over living in two cities in Yamagata Prefecture has been followed. Sixty-three subjects (24 men, 39 women) were classified as rank A (homebound). Fifty-two persons completed the baseline survey in 1999 and 46 eligible persons (18 men and 28 women) were allocated to intervention and control groups whose age and sex distribution were matched. Intervention entailed giving some health information and Life Review processing for four months, twice a month on average. Each session started with provision of health information followed by the Life Review process which took an hour to finish. All subjects of both groups were assessed for dependent variables at the beginning and the end of the intervention period (pretest and post-test). Dependent variables were physical (Activities of Daily Living, Visual deficit, and others), psychological (subjective health, life satisfaction, self-efficacy scale, and others), and social (functional ability and frequency of getting out of the house). The control group received only the pretest and the post-test. RESULTS: Pretest scores for all physical, psychological, and social variables did not significantly differ between the two groups. The rate for improvement/no change were higher with regard to hearing deficit, ADL (eating, dressing), cognition, subjective health, ikigai and frequency of getting out of house in the intervention group than in the control group, but there were no significant differences. CONCLUSION: The developed intervention program featuring delivery of health information and structured Life Review Process had no negative influence on physical and psycho-social functions. Practicability of the intervention was suggested. But the study highlights problems such as selection of subjects, duration and method of intervention.

[Predictors of functional status among independent and homebound community dwelling elderly: physical, psychological, and social parameters].

PURPOSE: The purpose of this study was to determine changes in functional status of Japanese community-dwelling elderly, and to identify physical, psychological, and social factors that predict functional change in a 1-year longitudinal study. METHODS: A cohort of people 65 years of age and over living in two cities in Yamagata Prefecture were followed for one year. The employed degree of independent criteria developed by the Ministry of Health and Welfare had nine levels. Subjects were classified as independent (rank J) and homebound (rank A) and numbered 112 and 53, respectively. Data on demographic, physical, psychological, and social variables were collected in 1997 by mail and interview during house visits. Death and change in functional status were checked in 1998. RESULTS: At follow-up, 1.0% of independent elders had died. Likewise, of the homebound elderly 7.7% had died. Change in functional status between the baseline and follow-up surveys were similar for both sexes and all age groups. According to nine levels criteria, rates for a good and a poor functional status of independent elderly were much the same at the baseline. Among homebound elders, 35.4% demonstrated improvement in the functional status and 14.6% deterioration. Among independent elderly, worsening of the functional status was significantly displayed, particularly with regard to hearing deficits, hospitalization within the past one year, loss of self-efficacy, fair or poor subjective health and poor functional ability. Among homebound elderly, worsening was significantly displayed in term of incontinence and poor self-efficacy. CONCLUSIONS: When functional status at baseline was poor, deterioration was evident at follow-up survey, independent of the sex or age group. Transition in functional status can be dynamic, and improvement was more usual than worsening among homebound elderly. Our results show that increase in self-efficacy can be an effective target in programs for improvement of functional status and for prevention of functional deterioration among the independent and homebound elderly of both sexes.