Original Research

Elder Abuse andDepressive Symptoms:
Which is Cause andEffect? Bidirectional
Longitudinal Studies
From the JAGES

Journal of Interpersonal Violence
1­–17© The Author(s) 2020

https://doi.org/10.1177/0886260520967135
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DOI: 10.1177/0886260520967135
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Chie Koga,1 Taishi Tsuji,1 Masamichi Hanazato,1
Norimichi Suzuki,1 and Katsunori Kondo1,2Abstract
Elder abuse is a serious public health concern that increases the risks ofnegative health outcomes globally. It is well known that abuse in older adults
is associated with depression; however, longitudinal studies investigating
the causal relationship between these events are scarce. Because the cause
precedes the result over time, the temporal relationships between abuseand depression should be verified from each direction. This longitudinal
study, therefore, investigated and clarified whether depression causes or
results from elder abuse among older Japanese adults. Two longitudinal
analyses were conducted using data derived from the Japan Gerontological
Evaluation Study. The data were collected in 2010 and 2013 through a mailsurvey of 1,737 people (983 females, 754 males) across Japan. Of those who
did not experience abuse in 2010, 38 (5.0%) males and 53 (5.4%) females
newly experienced abuse in 2013. Among respondents who did not havedepressive symptoms in 2010, 60 (8.0%) males and 61 (6.2%) females newly
reported depressive symptoms in 2013. After adjusting for demographic
factors in Analysis 1, people who experienced abuse were 2.28-fold (95%
1Chiba University, Chiba, Japan
2National Center for Geriatrics and Gerontology, Obu, Japan

Corresponding Author:
Chie Koga, Chiba University, Chiba 260-8670, Japan
E-mail: chiekoga@chiba-u.jp

2Journal of Interpersonal Violence

confidence interval [CI] = 1.68–3.09) more likely to have depressive
symptoms three years later than those who were not abused. In Analysis
2, respondents who had mild or severe depression in 2010 were 2.23-fold(95% CI = 1.61–3.10) more likely to have experienced abuse after three
years than those who did not have depression. After adjusting for several
demographic factors, the results showed that abuse can lead to depression
and that depression can be a cause of abuse. Therefore, preventing abuseshould be considered from both directions.
Keywords
elder abuse, mental health and violence, predicting domestic violence,
domestic violence, preventing violence

Introduction
Elder abuse is one of the serious public health issues that increases the risk ofnegative health outcomes in low-, middle-, and high-income countries (Abdiet al., 2019; Pillemer et al., 2016; World Health Organization (WHO), 2014;
Yon et al., 2017). The many risk factors of elder abuse have been categorized
in different levels such as individual, perpetrator, individual–perpetrator relationships, and social or community levels (Johannesen & Logiudice, 2013).
In addition, several studies have revealed strong associations between
elder abuse and depressive symptoms (Park, 2018; Pillemer et al., 2016;
Roepke-Buehler et al., 2015; Santos et al., 2017). Depressive symptoms are
known risk factors for many negative health outcomes (Soysal et al., 2017).
For example, depressive symptoms are associated with increased rates ofmorbidity and suicide (Hawton et al., 2013). Therefore, these symptoms represent an urgent issue that must be resolved. However, although several previous studies described the association between elder abuse and depressive
symptoms, their causal relationship has not been clarified; that is, it is unclear
whether depression is a cause of elder abuse. To date, research has only
investigated the correlation between abuse and depression. Although abuse
as a cause of depression has been shown, whether depression leads to abuseremains unknown. While it is conceivable that being abused by someone you
trust could cause depression, it is also conceivable that weakness caused bydepression or other factors results in increased risk of abuse.
Gaining insight into the cause-and-effect relationship between elder abuseand depressive symptom would assist in elucidating the mechanisms of elder
abuse and mental illness, which would be useful from a public health perspective considering the implications for treatment of depression and prevention of abuse in older adults in Japan. Because cause precedes result, the3

Koga et al.

temporal relationship between abuse and depression should be verified.
Therefore, in this study, we examined the relationship between elder abuseand depressive symptoms from both directions using longitudinal data fromindependent older people living in Japan.

Methods
Study Design and Respondents
We used a longitudinal data from the Japan Gerontological Evaluation Study(JAGES) collected via mail survey in 2010 and 2013 (Kondo & Rosenberg,
2018). This was a population-based study of independent adults aged 65
years or older who did not have physical or cognitive disabilities and were
not eligible for public long-term care insurance benefits. The municipalities
included urban, suburban, and rural communities throughout Japan. Although
the JAGES respondents were not randomly selected, the data covered a wide
range and size of community populations. For the present study, we randomly
selected data from one-fifth of the JAGES participants in both 2010 and2013, totaling 1,737 individuals (Figure 1).
Baseline survey
2010

Enrollment for the 1st survey (n = 110,673)
No response n = 35,202
Responded participants (n = 75,471)(Response rate: 67.3%)

Follow-up survey
2013

Death and moved out n = 3,726
Receiving public long-term care insurance benefits n = 6,045
Non-response and invalid ID number, sex, age n = 29331

Valid respondents to the follow-up survey: n = 36,369

In both 2010 and 2013, the abuse item
was randomly sampled 1/5, so the answer to both wasapproximately 1/25 of the total. n = 34,632

Total analytic participants:
n = 1,737

Figure 1. Flow chart showing participants in this study.

4

Journal of Interpersonal Violence

Measurements
Elder abuse.
Elder abuse was measured in three dimensions: physical, psychological, andfinancial abuses in both 2010 and 2013. Questionnaires were designed by thecollective effort of several researchers (including medical doctors, social epidemiology researchers, and social workers). Because there is no official andestablished definition of abuse, clarifying the criteria for judging the type,
frequency, and duration of behavior that constitutes elder abuse is difficult. In
this study, questionnaires were designed to identify specific actions that
respondents had endured, such as being hit, harm to their self-esteem, andtaking of their savings/pension benefits to confirm the presence or absence ofabuse. Three questions were asked to identify abuses, and integrated them tocreate a variable abused or not. For physical abuse, respondents were asked,“In the past year, did you ever experience physical violence from your family,such as being hit, kicked, having objects thrown at you, or being shut in aroom?” For psychological abuse, they were asked, “In the past year, did you
ever experience an act by your family that harmed your self-esteem, such asverbal abuse, cutting remarks, or being ignored for long periods?” Answer
options to both questions were on a four-point scale as follows: 1 = never; 2= once or twice; 3 = occasionally; and 4 = frequently. Those who answered 1
were considered nonabused, whereas those answering from 2 to 4 were considered abused. Concerning financial abuse, respondents were asked, “Do
any of your family members take or use your savings or pension benefits
without your consent?” The answer was either yes or no, with the former
categorized as abuse and the latter as nonabuse. These three variables werethen integrated to create a single variable for abuse (Koga et al., 2020).
Depressive symptoms.
Depression symptoms were also measured in both 2010 and 2013 using the15-item Geriatric Depression Scale, which defines mild depression as >5 points
and severe depression as >10 points (Haseda et al., 2017; Saito et al., 2017).
Covariates.
According to previous research, we analyzed basic demographic information,
including sex, age (65–69, 70–74, 75–79, 80–84, or ≥85 years), education level(≤9 or ≥10 years), equivalent income (low [≤1,999,999 JPY (100JPY ≈ 1USD)],
middle [2,000,000–3,999,999 JPY], or high [≥4,000,000 JPY]), marital status(married, widowed, divorced, unmarried, or other), and living arrangements(living alone, with family members, or other facility) (Dong et al., 2014; Kondo& Rosenberg, 2018; Sooryanarayana et al., 2017; Wu et al., 2012). To assess

Koga et al.

5activity of daily living (ADL) independence, participants were asked, “Do you
regularly receive nursing care or assistance for walking, bathing, and/or usinga toilet?” Answers options were on a three-point scale as follows: 1 = no needfor nursing care or assistance; 2 = requiring but not receiving nursing care or
assistance; 3 = needing and receiving nursing care or assistance.

Statistical Analysis
We conducted a descriptive analysis to summarize the characteristics of theparticipants. In both 2010 and 2013, the abuse item was randomly sampled
1:5, and thus, the answer to both was approximately 1/25th of the total.
Therefore, the final analyzed population of this study was 1,737 older adults.
Cramér’s V was calculated to confirm that the selected participants comprised a representative sample of the population before random sampling.
Previous studies demonstrated that Cramér’s V denotes weak association at
the values of 0.1–0.2, whereas values <0.1 indicate negligible association(Lee, 2016). Since variables such as abuse and depressive symptoms in thisanalysis contained missing data, we performed multiple imputation. In total,
20 multiple imputed datasets including all measurement variables using themultivariate normal imputation method under a “missing at random” assumption were created, and the estimated parameters combined using Rubin’s
combination method. Logistic regression analyses were conducted to investigate the causal relationship between abuse and depressive symptoms. Twoanalysis were performed to investigate each direction of the relationship. In
the first analysis (Analysis 1), to investigate the effect of elder abuse on
depressive symptoms, respondents without depressive symptoms in 2010served as the baseline group (abuse in 2010 vs. no abuse in 2010 for predicting depression in 2013). In the second analysis (Analysis 2), which investigated the effect of depressive symptoms on abuse, respondents who had notbeen abused served as the baseline group (depression in 2010 vs. no depression in 2010 for predicting abuse in 2013). Stata 16/IC (StataCorp, College
Station, TX, USA) was used for all statistical analyses.

Results
The characteristics of the 1,737 study respondents are shown in Table 1.
Among all the respondents, 754 (43.4%) were male, whereas 983 (56.6%)
were female. The characteristics of the respondents who were excluded via
random sampling (n = 34,632) is presented in the Appendix as a table. The
random sampling was considered representative as Cramér’s V was >0.1 forall variables (Lee, 2016). More than half of the subjects were ≤74 years old,

6

Journal of Interpersonal Violence

844 (48.6%) had an education level of ≥10 years, 671 (38.6%) were low
equivalent income, 1,262 (72.7%) were married, and 1,449 (83.4%) were living with family members in 2010. Among those who did not experience
abuse in 2010, 38 (5.0%) males, and 53 (5.4%) females experienced newonset abuse in 2013. In addition, 60 (8.0%) males and 61 (6.2%) females had
depressive symptoms in 2013 but not in 2010.
Table 1. Characteristics of Respondents.
All, n = 1,737 Male, n = 754 Female, n = 983
n

%

n

%

%

n

Newly depressed in 2013

121

7.0

60

8.0

61

6.2

Newly abused in 2013

93

5.4

38

5.0

53

5.4

No abuse in 2010

1,338

77.0

594

78.8

744

75.7

Abused in 2010

224

12.9

92

12.2

132

13.4

Missing

175

10.1

68

9.0

107

10.9

No abuse in 2013

1,435

82.6

626

83.0

809

82.3

Abused in 2013

186

10.7

77

10.2

109

11.1

Missing

116

6.7

51

6.8

65

6.6

Elder abuse

Elder abuse

Depression (GDS)
Normal in 2010

1,150

66.2

507

67.2

643

65.4

Mild or severe depressive in
2010

348

20.0

172

22.8

176

17.9

Missing

239

13.8

75

9.9

164

16.7

1,069

61.5

480

63.7

589

59.9

Mild or severe depressive in
2013

332

19.1

156

20.7

176

17.9

Missing

336

19.3

118

15.6

218

22.2

65–69

576

33.2

270

35.8

306

31.1

70–74

524

30.2

215

28.5

309

31.4

75–79

391

22.5

169

22.4

222

22.6

80–84

188

10.8

79

10.5

109

11.1

≥85

58

3.3

21

2.8

37

3.8

Depression (GDS)
Normal in 2013

Age (years)(continued)

7

Koga et al.
Table 1. continued

All, n = 1,737 Male, n = 754 Female, n = 983
n

%

n

%

n

%

≤9

843

48.5

338

44.8

505

51.4

≥10

844

48.6

403

53.4

441

44.9

Missing

50

2.9

13

1.7

37

3.8

Educational level (years)

Equivalent income (JPY (100JPY ≈ 1USD))
Low (≤1,999,999)

671

38.6

280

37.1

391

39.8

Middle (2,000,000–3,999,999) 576

33.2

293

38.9

283

28.8

High (≥4,000,000)

200

11.5

98

13.0

102

10.4

Missing

290

16.7

83

11.0

207

21.1

Married

1,262

72.7

661

87.7

601

61.1

Widowed

377

21.7

60

8.0

317

32.2

Divorced

42

2.4

14

1.9

28

2.8

Unmarried

21

1.2

5

0.7

16

1.6

Missing

35

2.0

14

1.9

21

2.1

Living alone

161

9.3

40

5.3

121

12.3

With family members

1,449

83.4

645

85.5

804

81.8

Other facilities

107

6.2

58

7.7

49

5.0

Missing

20

1.2

11

1.5

9

0.9

Marital status

Living arrangement

Odds ratios (ORs) with 95% confidence intervals (CIs) for the causal relationship between elder abuse and depressive symptoms among older Japanese
adults from Analyses 1 and 2 are shown in Table 2. After adjusting for demographic factors in analysis 1, subjects who experienced abuse were 2.28 (95%CI = 1.68–3.09) times more likely to have depressive symptoms in 2013 thanrespondents who did not receive abuse. In contrast, those participants wereless likely to have depressive symptoms after three years. Those were female(OR = 0.74, 95% CI = 0.58–0.95), had education level ≥10 years (OR = 0.52,
95% CI = 0.41–0.66), middle (OR = 0.62, 95% CI = 0.47–0.80) or highequivalent income (OR = 0.49, 95% CI = 0.32–0.75). Meanwhile, respondents who are 70–74 years old were 1.37 (95% CI = 1.01–1.85) times, 75–79
years old were 1.51 (95% CI = 1.09–2.09) times, 80–84 years old were 1.87
(95% CI = 1.25–2.80) times, and 85 or older were 1.93 (95% CI = 1.01–3.68)
times more likely to have mild or severe depression.

1.00

0.74

Male

Female2.28

Abused in 2010

.045

1.51

1.87

1.93

75–79

80–84

1.00

0.52

≤9

≥10

Educational level

≥85

.002

1.37

70–74

<.001

.013

1.00
.042

.017

<.001

p

65–69

Age (years)

Sex

1.00

No abuse in 2010

Odds
Ratio

0.41

1.01

1.25

1.09

1.01

0.58

1.68

0.66

3.68

2.80

2.09

1.85

0.95

3.09

95%
ConfidenceInterval

Analysis 1: Abuse in 2010 vs. No Abuse in 2010 Predicting
Depression in 2013

≥10

≤9

≥85

80–84

75–79

70–74

65–69

FemaleMale

Mild or severe depressive in 2010

Normal in 2010

0.83

1.00

0.74

0.51

0.79

1.02

1.00

1.40

1.00

2.23

1.00

Odds
Ratio

.243

.535

.046

.301

.916

.042

1.14

1.94

0.99

1.23

1.47

1.94

3.10

(continued)

0.61

0.28

0.27

0.51

0.71

1.01

<.001 1.61

p

95%
ConfidenceInterval

Analysis 2: Depression in 2010 vs. No Depression in 2010
Predicting Abuse in 2013

Table 2. Odds Ratios With 95% Confidence Intervals for the Longitudinal Relationship Between Elder Abuse and Depressive Symptoms
From Analyses 1 and 2 (n = 1,737).

0.62

0.49

Middle (2,000,000–3,999,999)

High (≥4,000,000)

1.27

1.33

2.58

WidowedDivorced

Unmarried

1.00

0.95

1.41

Living alone

With family members

Other facilities

Living arrangement

1.00

MarriedMarital status

1.00

Low (≤1,999,999)

Equivalent income (JPY (100JPY ≈ 1USD))

Odds
Ratio

.291

.809

.058

.454

.166

<.001

<.001

p

0.74

0.60

0.97

0.63

0.91

0.32

0.47

2.69

1.49

6.85

2.78

1.78

0.75

0.80

95%
ConfidenceInterval

Analysis 1: Abuse in 2010 vs. No Abuse in 2010 Predicting
Depression in 2013

Table 2. continued

Other facilities

With family members

Living alone

Unmarried

Divorced

WidowedMarriedHigh (≥4,000,000)

Middle (2,000,000–3,999,999)

Low (≤1,999,999)

2.15

1.95

0.51

1.58

0.62

1.00

1.17

0.92

1.00

Odds
Ratio

.120

.110

.506

.326

.056

.539

.630

p

0.82

0.86

0.07

0.64

0.38

0.70

0.65

5.64

4.42

3.77

3.91

1.01

1.95

1.30

95%
ConfidenceInterval

Analysis 2: Depression in 2010 vs. No Depression in 2010
Predicting Abuse in 2013

10

Journal of Interpersonal Violence

In Analysis 2, respondents who had mild or severe depression in 2010
were 2.23 (95% CI = 1.61–3.10) times more likely to have experienced abuse
than those who did not have depressive symptoms after three years. Moreover,
respondents who were female were 1.40 (95% CI = 1.01–1.94) times more
likely to have experienced abuse.

Discussion
This study investigated the relationship between elder abuse and depressive
symptoms from each direction using longitudinal data for independent older
people living in Japan. The results illustrate that depressive symptoms areboth a cause and consequence of abuse. To the best of our knowledge, this is
the first study to investigate the relationship between elder abuse and depressive symptoms from each direction using one dataset.
This study shows that respondents who experienced abuse in 2010 were2.28 times more likely to have depressive symptoms in 2013. Regarding
depression attributable to abuse, violence from family members may lead toanxiety about the future and contribute to the onset of depressive symptoms
because of feelings of despair. When older adults have no one with whom toshare their abusive experiences, depressive symptoms might develop. Several
previous studies have found that social support might be a preventive factor
for abuse (Chokkanathan, 2017; Dong & Simon, 2008; Koga et al., 2020).
Thus, a lack of expected support from family members or a lack of support
itself could also lead to depressive symptoms. Moreover, depressive symptoms may be an intermediate factor between abuse and suicide. Consideringa previous study found that abuse is associated with suicide, suicide may
occur after depressive symptoms in older adults (Hawton et al., 2013; Luo &Waite, 2011). It is possible that older adults may be in an environment where
they are not able to seek help from those around them and develop depressive
symptoms because of abuse. In Asia, due to cultural influences, older adults
who have been abused are often reluctant to disclose abuse in order to protect
the honor and dignity of their families (Moon et al., 2002). This lonelinessmay increase the risk of developing depressive symptoms.
Moreover, our finding indicates that respondents who have depressive
symptoms were 2.23 times more likely to experience abuse three years later.
Respondents who already had depressive symptoms may be prone to perceive any aggressive action as abuse, which could lead to exaggeration. For
example, previous studies have reported that frailness or functional dependence due to depression can cause people to misinterpret certain situations as
abuse (Curcio et al., 2019; Dong, 2017; Soysal et al., 2017). Another study
discussed the possibility of abuse associated with chronic pain (Yunus et al.,

Koga et al.

112018). Based on these findings, depression, which results in emotional and/or physical limitations, may make people more vulnerable to abuse. In addition, people with depression or physical frailty are more easily attacked thantheir healthy counterparts. This phenomenon is not unique to Japanese or
Asian cultures, but is thought to be common.
Abuse typically occurs as part of an ongoing downward spiral (RoepkeBuehler et al., 2015). Thus, subjects could experience abuse and have depressive symptoms almost contemporaneously, and it may be difficult to identify
a causal relationship. Some studies have revealed that children tend to beabusers of their parents (Kulakçı Altıntas¸ & Korkmaz Aslan, 2019;
Melchiorre et al., 2014; Yan et al., 2015;). Families have long histories, andthe relationship between family members might vary over time. To exit thisvicious cycle, preventive strategies for abuse and depressive symptoms
should be considered from both directions. It has been suggested that social
capital may have a preventive and ameliorative effect on both elder abuse anddepressive symptoms. Social capital is comprised of the norms, networks,
and associations that facilitate actions in the community (Putnam, 1993). For
instance, those who have social support have a lower risk of experiencing
elder abuse and depressive symptoms (Johannesen & Logiudice, 2013;
Sasaki et al., 2019). In addition, another study has shown a relationshipbetween elder abuse and social cohesion (Koga et al., 2020). Because ourstudy confirmed the bidirectional relationship between elder abuse anddepressive symptoms, the increased positive aspect of social capital may leadto a break from the downward spiral of abuse and depression, as the causes ofabuse and consequences of depression can be efficiently approached.
Several limitations of this study should be mentioned. First, the questionnaires to identify abuse were not validated. Therefore, validation should be
performed in future studies. Second, we excluded respondents who weredependent in terms of ADLs and those receiving public long-term care insurance benefits; therefore, the study sample was not nationally representative.
Some studies have demonstrated that ADL-dependent respondents are more
likely to be abused (Johannesen & Logiudice, 2013). Therefore, the actual
incidence of abuse might have been underestimated in this study. Third, toverify the causal relationship, data analysis considering the time until theoccurrence of an outcome and Cox proportional hazard analysis are the main
methods. Randomized control trials (RCTs) are also recommended to investigate the causal relationship. However, because there was no time or RCT
data until the abuse occurred in this study, we considered that time consideredusing the available data at both time points. Finally, respondents with depressive symptoms may have exaggerated their report of abuse.

12

Journal of Interpersonal Violence

Conclusion
The two longitudinal analyses of this study show that depression is both acause and consequence of elder abuse, illustrating a bidirectional relationship. Prevention strategies from both directions are necessary to avoid adownward spiral of abuse and depression.
Acknowledgment
This study used data from JAGES, conducted by the Nihon Fukushi University Center
for Well-Being and Society. We are extremely grateful to all study participants for theuse of their personal data. We would like to express our deepest gratitude to everyone
who participated and cooperated in the surveys.
Appendix. Comparison Between Analyzed Participants and Others.
1/25(Analyzed
Participants)
n = 1,737
n
%
Sex
Male
754
Female983
Age (years)
65–69
576
70–74
524
75–79
391
80–84
188
≥85
58
Educational level (years)
≤9
843
≥10
844
Missing50
Equivalent income (JPY (100JPY ≈ 1USD))
Low (≤1,999,999)
671
Middle (2,000,000–3,999,999)
576
High (≥4,000,000)
200
Missing290

24/25 (Before
RandomSampling)
n = 34,632
n%Cramer's V

43.4 15,894
56.6 18,738

45.9
54.1

0.010633.2 11,379
30.2 10,435
22.5 7,550
10.8 3,897
3.3 1,371

32.9
30.1
21.8
11.3
4.0

0.008048.5 17,525
48.6 16,403
2.9
194

50.6
47.4
0.6

0.007838.6 14,365
33.2 11,310
11.5 3,127
16.7 5,830

41.5
32.7
9.0
16.8

0.0219(continued)

13

Koga et al.
Appendix. continued

1/25(Analyzed
Participants)
n = 1,737n%Marital status
MarriedWidowedDivorced
Unmarried
Missing
Living arrangement
Living alone
With family members
Other facilities
Missing

24/25 (Before
RandomSampling)
n = 34,632
n%Cramer's V

1,262
377
42
21
35

72.7 25,256
21.7 7,175
2.4
938
1.2
500
2.0
763

72.9
20.7
2.7
1.4
2.2

0.0078

161
1,449
107
20

9.3 3,370
83.4 28,836
6.2 1,939
1.2
487

9.7
83.3
5.6
1.4

0.0060Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,authorship and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,authorship and/or publication of this article: This study was supported by the Ministryof Education, Culture, Sports, Science and Technology-Japan supported Program for
the Strategic Research Foundation at Private Universities (20092013), JSPS (Japan
Society for the Promotion of Science) KAKENHI (grant Nos. JP22330172,
JP22390400, JP23243070, JP23590786, JP23790710, JP24390469, JP24530698,
JP24683018, JP25253052, JP25870573, JP25870881, 19K04785 and 20K13721),
Health Labor Science Research Grants (H22-Choju-Shitei-008, H24-Junkanki[Seishu]-Ippan-007, H24Chikyukibo-Ippan-009, H24-Cho- ju-Wakate-009, H25Kenki-Wakate-015, H26-Irryo-Shitei003 [Fukkou], H25-Choju-Ippan-003, and H26Choju-Ippan-006) from the Ministry of Health, Labor and Welfare, Japan, theResearch and Development Grants for Longevity Science from AMED (Japan Agency
for Medical Research and Development), a grant from the National Center for
Geriatrics and Gerontology, Japan (24-17, 24-23), and a JST-OPERA program grant(JPMJOP1831).

14

Journal of Interpersonal ViolenceStatement of Ethics
The JAGES protocol was reviewed and approved by the Ethics Committee on
Research of Human. Ethical approval for the study was obtained from the Ethics
Committee at Nihon Fukushi University, Japan (approval No. 10-05) and the Ethics
Committee at the Chiba University Faculty of Medicine, Japan (approval No. 2493).

ORCID iDs
Chie Koga

https://orcid.org/0000-0002-1971-4308

Taishi Tsuji

https://orcid.org/0000-0002-8408-6619

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Author Biographies
Chie Koga, PhD, is a researcher in the Center for Preventive Medical Sciences, Chiba
University, Japan. Her research focuses on preventing elder abuse through environmental factors such as social capital. She is a member of JAGES groups which collaborate with various municipalities in Japan. Through JAGES, she evaluatesenvironmental factors and support policy making of each community.
Taishi Tsuji, PhD, is an assistant professor at the Faculty of Health and Sport
Sciences, University of Tsukuba. He is a member of JAGES groups which collaborate
with various municipalities in Japan. Through JAGES, he is engaged in social epidemiology and exercise epidemiology.
Masamichi Hanazato, PhD, is an associate professor in the Center for Preventive
Medical Sciences, Chiba University, Japan. He is a member of JAGES groups whichcollaborate with various municipalities in Japan. Through JAGES, he works in analysis of environment and health.
Norimichi Suzuki, PhD, is an associate professor in the Center for Preventive
Medical Sciences, Chiba University, Japan. His focus is public health and social medicine from the viewpoint of urban planning. He is a member of JAGES groups whichcollaborate with various municipalities in Japan. Through JAGES, he works in analysis of social epidemiology and the built environment.
Katsunori Kondo, MD, PhD, is a professor of social epidemiology and health policy
at the Center for Preventive Medical Sciences and the Graduate School of Medicine
at Chiba University. He is also Head of the Department of Gerontological Evaluation
at the Center for Gerontology and Social Science, National Center for Geriatrics andGerontology.