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OPEN

Association of functional
competencies with vaccination
among older adults: a JAGES
cross‑sectional study
Kousuke Iwai‑Saito1*, Koryu Sato2 & Katsunori Kondo3,4
It is unknown whether higher functions in sublevels of competence other than instrumental activities
of daily living (IADL) are associated with vaccinations. This study examined whether higher functions,
including intellectual activity (IA) and social role (SR), were associated with vaccinations among
26,177 older adults. Older adults with incapable activities in IA and SR had increased risks for nonreceipt of influenza vaccinations (IA: for one incapable task/activity: incident rate ratio (IRR) = 1.05,
95% confidence interval (CI) = 1.02–1.09; SR: for two incapable tasks: IRR = 1.12, 95% CI = 1.08–1.16).
Those with incapable activities in IADL and IA had increased risks for non-receipt of pneumococcal
vaccination (IADL: for two incapable tasks: IRR = 1.13, 95% CI = 1.05–1.23; IA: for two incapable tasks:
IRR = 1.10, 95% CI = 1.08–1.12). Those with incapable activities in IADL, IA, and SR had increased
risks for non-receipt of both of the two vaccinations (IADL: for two incapable tasks: IRR = 1.17, 95%
CI = 1.03–1.33; IA: for two incapable tasks: IRR = 1.18, 95% CI = 1.11–1.25; SR: for two incapable tasks:
IRR = 1.13, 95% CI = 1.07–1.20). Having a family physician mitigated associations for non-receipt,
regardless of competency. Our results suggest—maintaining the higher functions are important for
older adults to undergo recommended vaccinations as scheduled; also, having a family physician topromote vaccinations is beneficial even for older adults with limited functions.
Influenza and pneumonia become more severe or lethal in older adults aged 65 years compared to younger adults.
Human influenza viruses A and B typically cause mild respiratory illness and infection of the lower respiratory
tract, which can progress to pneumonia, acute respiratory distress syndrome or secondary bacterial infection,and death from respiratory ­failure1. An average of 389,000 respiratory deaths were estimated to be associatedwith influenza worldwide each year during the study period, or ~ 2% of all annual respiratory deaths and 67% of
these were among older adults aged ≥ 65 ­years2. Pneumonia is a major cause of mortality and morbidity amongolder adults. Streptococcus pneumoniae is a leading cause of morbidity and mortality of the illness globally, contributing to 1,189,937 deaths, which is more than all other e­ tiologies3
Influenza and pneumococcal vaccinations are effective in preventing older adults from these severe i­ llnesses4,5.
However, social, or geriatric factors may hamper them from receiving vaccinations. For example, living alone,paucity of social c­ apital6–8, and cognitive impairment can be risk factors for non-receipt of vaccinations amongolder ­adults9. The lower capability of instrumental activity of daily living (IADL) is one such geriatric factor
among older adults. IADL is a measure for assessing “instrumental self-maintenance,” which was defined as
one of Lawton’s seven sublevels of competence, which include life maintenance, functional health, perception
and cognition, physical self-maintenance, effectance, and social role (SR)10. Manias et al. recently reported thatthe lower capability in IADL was associated with the lower uptake of influenza and pneumococcal vaccinations
among older adults aged 65 years and more 3 months after discharged from geriatric ­rehabilitation11. However,
it is unknown whether higher-level functions of competency other than IADL, such as intellectual activity (IA)and SR, are associated with influenza and pneumococcal vaccination uptake in older adults. Examining theseassociations is important because higher-level functions are more likely to be lost as aging than I­ ADL12.
1

Division of International Health, Graduate School of Medical and Dental Sciences, Niigata University, Niigata,Japan. 2Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto
University, Kyoto, Japan. 3Department of Social Preventive Medical Sciences, Center for Preventive Medical
Sciences, Chiba University, 1‑8‑1, Inohana, Chuo‑Ku, Chiba 360‑0856, Japan. 4Department of Gerontological
Evaluation, Center for Gerontology and Social Science, Research Institution, National Center for Geriatrics andGerontology, Aichi, Japan. *email: anayoshi@med.niigata-u.ac.jp

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As a result, we evaluated whether lower capabilities of the higher functions, including IA and SR, were associated with non-receipt of influenza and pneumococcal vaccinations among community-dwelling older adults aged
65 years or more. Furthermore, we hypothesized that having a family physician could mitigate the relationshipbetween competency deterioration and non-receipt of the vaccinations and assessed its effect m­ odification13.

Methods

Study design and participants.

This study had a cross-sectional design and used data from the Japan
Gerontological Evaluation Study (JAGES). In Japan, this study looked at the social determinants of healthamong non-institutionalized and functionally independent people aged 65 years and more who did not requireassistance from public long-term care insurance. We mailed self-reported questionnaires to older adults in 64
municipalities from November 2019 to January 2020. We invited 45,974 individuals, and 31,495 returned thequestionnaire, corresponding to a response rate of 68.5%. We excluded 5,318 people from the study because they
did not agree with the academic consent, were under the age of 65 years, or did not provide information about
their age or sex. As a result, the analytical data consisted of 26,177 individuals.

Outcome variables. The outcome variable was non-receipt of influenza, pneumococcal, or the both vaccinations according to the recommended ­schedule14–16. We examined the three outcomes separately because
our recent study suggested heterogeneous determinants of the ­vaccinations13 and we found that the participants
who received neither of the two vaccinations were prevalent among all the participants (24.1%, Supplemental
Table 4). We asked, “Did you get an influenza vaccination in the last year?” and “Did you get a pneumococcal
vaccination in the last 5 years?” We created binary variables for influenza, pneumococcal, or both of the two vaccinations 1 indicating those who did not undergo the vaccination and 0 indicating otherwise.
Explanatory variables. Explanatory variables were the incapability of IADL, IA, and SR, measured using

the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC)17. The IADL was assessedby asking the participants, “Can you go out alone by train or bus?” “Can you go shopping for daily necessities?”“Can you cook for yourself?” “Can you pay your bills by yourself?” “Can you deposit or withdraw money fromyour bank/postal savings account(s) by yourself?” For each question, we assigned 1 for those who answered,“No, I can’t,” and 0 for those who answered, “Yes, I can and do,” or “Yes, I can but usually don’t.” We added thenumber of incapable activities and categorized it into 0, 1, 2, and more. IA was assessed by asking participants,“Can you complete paperwork for your pension or other reasons (e.g., documents submitted to your local government offices, clinics/hospitals, etc.) by yourself?” “Do you read newspapers?” “Do you read books or magazines?” “Are you interested in health-related articles or TV programs?” SR was assessed by asking participants,“Do you visit your friends’ homes?” “Do you advise your family members or friends?” “Can you visit people whohave fallen ill?” “Do you start conversations with young people?” For IA and SR, there were yes/no options. We
assigned 1 for the response of “No” and 0 for “Yes” and categorized the number of incapable activities for IA and
SR into 0, 1, 2 and more. In addition, the total number of incapable activities in the TMIG-IC (i.e., the sum of
IADL, IA, and SR) was also categorized into 0, 1, 2, and more. For IADL, IA, SR, and the TMIG-IC, we set 0 (i.e.,fully capable) for the reference group.

Covariates. For individual covariates, sociodemographic data, behavior, health status, and social relationship were used. Sociodemographic covariates consisted of sex, age (65–74 and ≥ 75 years), marital status (married, widowed, divorced, never married, and others), educational attainment (< 6, 6–9, 10–12, ≥ 13 years, andothers), equivalized income (< 0.5, 0.50–0.99, 1.00–1.99, 2.00–3.99, and ≥ 4.00 million yen), and household
structure (living alone, living with a spouse, living with offspring, living with a spouse and offspring, living ina three-generation household, and others)18. Behavioral covariates consisted of smoking status (never smoked,
quit smoking ≥ 5 years ago, quit smoking < 5 years ago, smoke sometimes, and smoke almost every day), selfrated health (excellent, good, fair, and poor), having a medical checkup (within 1 year, sometimes between 1 and4 years ago, > 4 years ago, and never), and having a family p­ hysician13. Patients’ questioning attitude was measured by asking, “How would you rate how well you were able to ask your physician about something you did notunderstand in the last visit?” (1 = poor, 2 = fair, 3 = good, and 4 = excellent)13. Health status covariates consistedof high-risk diseases associated with the severity of influenza and pneumonia (stroke, heart disease, diabetes,
respiratory disease, kidney/prostate disease, or blood/immune disease)19,20, history of influenza or pneumonia
in the past year, depressive symptoms (the short form of the geriatric depression scale: not depressed, depressive
tendency, or depression)21, and homeboundness (going to the field or immediate neighborhood, for shopping,to the hospital, etc.: once a week and more or less). Social relationship covariates consisted of civic participation,social cohesion, and ­reciprocity7,22–24.
Statistical analyses. We created the Directed Acyclic Graph (DAG) to identify a Minimal Sufficient

Adjustment Sets (MSAS) of potential confounders to estimate a direct effect of competence on influenza andpneumococcal vaccinations among older adults. We used an online tool, DAGitty v3.0 (http://​www.​dagit​ty.​net)
to create the DAG. The DAG analyses revealed that the MSAS to estimate the effects were age, sex, marital status, educational attainment, equivalized income, household structure, smoking status, self-rated health, medical checkup, family physician, patient’s questioning attitude, high-risk disease, pneumococcal or influenza vaccination, history of influenza or pneumonia, geriatric depression, homeboundness, civic participation, social
cohesion, and reciprocity. We generated 20 imputed data sets for handling missing data by using the chained
equations ­method25. Chi-squared tests were used for categorical variables. A Poisson regression model was used
to calculate the incident rate ratio (IRR) and 95% confidence interval (CI) based on robust standard errors for

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the association between the incapability of activities and non-receipt of vaccinations because the prevalence ofno vaccination exceeded 10%26,27. We carried out sensitivity analyses with the complete data set without missing
data as conducted in the imputed data sets. All P values were two-tailed and the significance was set at 5%. We
used Stata version 17.1 (Lightstone Corp., College Station, TX, USA) for all analyses.

Ethical consideration. The process of obtaining informed consent in the present study was as follows: thequestionnaire was sent by mail with the explanation of the study; the participants read the written explanation
about the purpose of study and replied. Hence, we considered that informed consent was provided by those who
replied and sent back the questionnaire. The JAGES protocol in 2019 was approved by the ethics committee of
National Center for Geriatrics and Gerontology (No. 992), the ethics committee of Chiba University (No. 2493),
and JAGES (No. 2019-01). We followed the STROBE Statement to report our observational study. This study
was performed in accordance with the principles of the Declaration of Helsinki. Informed consent was obtained
from all participants.

Institutional review board statement.

The study was conducted according to the guidelines of the Declaration of Helsinki. The JAGES Committee (no. 2019-01), the National Center for Geriatrics and Gerontology(no. 1274-2), and the Chiba University Ethics Committee (no. 3442) approved the parent JAGES protocol.

Results

Table 1 shows the variables of participants by the status of influenza, pneumococcal, and the both of the two
vaccinations. A percentage of older adults with normal capability in the IA or SR who received influenza vaccination was higher than those who did not receive the vaccination, while the percentage of those with normal
or the lower capability in the IADL or TMIG-IC with the vaccination was higher than those without it. Olderadults with the following characteristics were more likely to receive influenza vaccination than their counterparts:
aged ≥ 75 years, being female, being widowed, had education for > 6 or 6–9 years, had < 0.5 or ≥ 4.00 million yenof the equivalized income, lived with offspring, lived in a three-generation household, or lived in households
other than the five, never smoked, rated their health status as “good”, “fair”, or “poor,” had a medical checkup
within a year, had a family physician, rated their questioning attitude on a physician visit as “excellent,” had ≥1high-risk disease that potentially exacerbates influenza or pneumonia, received pneumococcal vaccination, had ahistory of influenza or pneumonia in the past year, was not depressed, was homebound, and had civic participation, social cohesion, or reciprocity. A percentage of older adults with normal capability in the IADL, IA, or SR
who received pneumococcal vaccination was higher than those without the vaccination, while the percentageof those with normal or the lower capability in the TMIG-IC with the vaccination was higher than those without
it. Those with the following characteristics were more likely to receive pneumococcal vaccination than theircounterparts: aged ≥ 75 years, being female, being married or widowed, had education for 6–9 or ≥13 years,
had 1.00–1.99 or ≥ 4.00 million yen of the equivalized income, lived with a spouse or offspring, lived in a threegeneration household, quit smoking ≥ 5 years ago or never smoked, rated their health status as “good”, had a
medical checkup within a year, had a family physician, rated their questioning attitude on a physician visit as“excellent,” had ≥1 high-risk disease, received influenza vaccination, had a history of influenza or pneumonia in
the past year, was not depressed, was not homebound, and had civic participation, social cohesion, or reciprocity. A percentage of older adults with normal capability in the IADL, IA, or SR who received either of the two
vaccinations was higher than those who received neither of the two vaccinations, while the percentage of thosewith either of the two was higher than those with neither of them. Those with the following characteristics weremore likely to receive either influenza or pneumococcal vaccination than their counterparts: aged ≥ 75 years,
being female, being married or widowed, had education for > 6 years, 6–9 years, had ≥ 4.00 million yen of theequivalized income, lived with spouse or offspring, lived in a three-generation household, quit smoking ≥ 5 years
ago or never smoked, rated their health status as “good”, “fair”, or “poor”, had a medical checkup within a year, hada family physician, rated their questioning attitude on a physician visit as “excellent,” had ≥1 high-risk disease a,
had a history of influenza or pneumonia in the past year, was not depressed, was not homebound, and had civic
participation, social cohesion, or reciprocity.
Table 2 shows the IRRs and 95% CIs for non-receipt of influenza, pneumonia, or the both vaccinations after
adjusting for all covariates. Incapability of IA, SR, or TMIG-IC was positively associated with non-receipt ofinfluenza vaccination (IA: for one incapable task/activity: IRR 1.05, 95% CI 1.02–1.09; SR: for one incapable task/
activity: IRR 1.08, 95% CI 1.04–1.12; for two incapable tasks/activities: IRR 1.12, 95% CI 1.08–1.16; TMIG-IC: for
two incapable tasks/activities: IRR 1.14, 95% CI 1.08–1.21). Unexpectedly, incapability of IADL was negatively
associated with influenza vaccination (one incapable task/activity: IRR 0.93, 95% CI 0.87–0.99) Incapability of
IADL or IA was positively associated with non-receipt of pneumococcal vaccination (IADL: for two incapabletasks/activities: IRR 1.13, 95% CI 1.05–1.23; IA: for two incapable tasks/activities: IRR 1.10, 95% CI 1.08–1.12).
Incapability of IADL, IA, SR, or TMIG-IC was positively associated with non-receipt of the both vaccinations(IADL: for two incapable tasks/activities: IRR 1.17, 95% CI 1.03–1.33; IA: for one incapable task/activity: IRR
1.07, 95% CI 1.02–1.13 and for two incapable tasks/activities: IRR 1.18, 95% CI 1.11–1.25; SR: for one incapabletask/activity: IRR: 1.06, 95% CI 1.01–1.12 and for two incapable tasks/activities: IRR 1.13, 95% CI 1.07–1.20;
TMIG-IC: for two incapable tasks/activities: IRR 1.14, 95% CI 1.08–1.21). The result of sensitivity analysis withthe complete data set without imputation was almost matched with the result analyzed with the imputed data
sets (Supplemental Table 2).
Table 3 shows IRRs and 95% CIs of interactions between IADL, IA, SR, or TMIG-IC and a family physician
on non-receipt of vaccinations. Having a family physician was negatively associated with non-receipt of influenza vaccination, regardless of incapability in IADL, IA, SR, or TMIG-IC (e.g., IADL: for two incapable tasks/
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Vaccination
Influenza

IADLIntellectual activity

Social role

TMIG-ICAge (years)
Sex

Marital status

Educational attainment

Equivalized income, million yen

Household structure (living with others or alone)

Smoking status

Self-rated health

Medical checkup

Family physician

Pneumococcal

Either (E) or neither (N)

Yes

SD

No

SD

Yes

SD

No

SD

E

SD

N

SD

0

90.7

0.23

91.3

0.29

91.5

0.23

90.2

0.30

91.1

0.20

90.6

0.37

1*

6.4

0.19

5.8

0.24

6.0

0.19

6.5

0.24

6.2

0.17

6.2

0.31

2**

2.9

0.13

2.9

0.17

2.6

0.13

3.3

0.18

2.8

0.12

3.2

0.22

0

67.0

0.37

61.8

0.51

67.5

0.38

61.5

0.49

66.8

0.34

59.8

0.63

1

22.4

0.33

25.2

0.45

22.5

0.34

24.8

0.43

22.7

0.30

25.6

0.56

2

10.6

0.24

13.0

0.35

10.0

0.25

13.7

0.34

10.4

0.22

14.6

0.45

0

50.3

0.40

43.4

0.53

50.0

0.41

44.4

0.51

49.6

0.36

42.2

0.65

1

26.1

0.35

27.5

0.47

26.5

0.36

26.7

0.45

26.4

0.32

27.1

0.58

2

23.6

0.33

29.2

0.48

23.5

0.34

28.8

0.46

24.0

0.31

30.6

0.59

0

38.6

0.39

32.5

0.49

38.6

0.41

33.1

0.47

38.1

0.36

31.0

0.60

1

25.2

0.35

24.5

0.46

25.4

0.37

24.3

0.43

25.3

0.32

24.0

0.55

2

36.2

0.38

43.1

0.53

36.0

0.40

42.6

0.50

36.6

0.35

45.0

0.65

65–74

46.8

0.39

62.2

0.50

49.1

0.40

57.3

0.49

49.4

0.36

61.5

0.62

≥ 75

53.2

0.39

37.8

0.50

50.9

0.40

42.7

0.49

50.6

0.36

38.5

0.62

Male

44.7

0.39

53.0

0.52

44.9

0.40

52.0

0.50

45.6

0.35

54.4

0.63

Female

55.3

0.39

47.0

0.52

55.1

0.40

48.0

0.50

54.4

0.35

45.6

0.63

Married

72.6

0.35

72.9

0.47

73.3

0.36

71.9

0.45

73.2

0.32

71.3

0.58

Widowed

20.3

0.32

16.3

0.39

19.5

0.32

17.8

0.38

19.4

0.28

16.9

0.48

Divorced

4.0

0.16

5.8

0.25

4.1

0.16

5.5

0.23

4.2

0.14

6.2

0.31

Never married

2.4

0.12

4.1

0.21

2.3

0.12

4.0

0.19

2.5

0.11

4.6

0.27

Other

0.7

0.07

0.8

0.10

0.7

0.07

0.9

0.09

0.7

0.06

1.0

0.13

<6

1.0

0.09

0.7

0.09

0.9

0.08

0.9

0.10

0.9

0.08

0.8

0.12

6–9

28.7

0.36

22.7

0.45

27.3

0.36

25.4

0.44

27.4

0.32

23.8

0.55

10–12

41.8

0.39

43.3

0.52

42.3

0.40

42.3

0.50

42.3

0.36

42.5

0.63

≥ 13

27.8

0.35

32.6

0.49

28.8

0.36

30.6

0.45

28.6

0.32

32.2

0.59

Others

0.8

0.07

0.8

0.09

0.8

0.07

0.8

0.09

0.8

0.06

0.8

0.11

< 0.5

11.8

0.25

11.1

0.33

11.2

0.26

12.0

0.33

11.4

0.23

12.0

0.41
0.60

0.50–0.99

30.0

0.35

32.7

0.49

30.2

0.37

32.1

0.46

30.3

0.33

33.1

1.00–1.99

19.6

0.31

20.5

0.42

20.1

0.32

19.7

0.39

19.9

0.28

20.0

0.51

2.00–3.99

13.7

0.27

14.9

0.37

14.1

0.28

14.1

0.34

14.1

0.25

14.1

0.44

≥ 4.00

24.9

0.34

20.9

0.42

24.3

0.35

22.2

0.41

24.3

0.30

20.9

0.52

A spouse

49.8

0.39

51.0

0.53

50.6

0.41

49.7

0.50

50.3

0.36

50.2

0.64

Alone

15.0

0.29

16.4

0.39

14.7

0.30

16.6

0.38

14.8

0.26

17.6

0.49

Offspring

7.7

0.22

7.0

0.27

7.6

0.22

7.2

0.27

7.6

0.20

6.9

0.33

A spouse and offspring

8.1

0.21

9.4

0.31

8.5

0.23

8.7

0.28

8.5

0.20

8.8

0.36

Three-generation household

10.6

0.24

7.6

0.28

10.2

0.24

8.5

0.28

10.1

0.22

7.7

0.34

Other than described above

8.9

0.22

8.5

0.29

8.4

0.22

9.3

0.29

8.7

0.20

8.8

0.36

Smoking almost everyday

6.3

0.19

12.3

0.34

6.2

0.19

11.9

0.32

6.8

0.18

13.8

0.44

Smoking sometimes

1.5

0.10

1.8

0.14

1.4

0.10

1.9

0.14

1.4

0.09

2.0

0.18

Quit smoking < 5 years ago

3.2

0.14

4.4

0.22

3.2

0.15

4.2

0.20

3.3

0.13

4.6

0.27

Quit smoking ≥ 5 years ago

27.1

0.35

28.5

0.47

27.7

0.37

27.5

0.44

27.6

0.32

27.5

0.57

Never smoked

61.9

0.38

53.0

0.52

61.5

0.40

54.5

0.49

60.8

0.35

52.0

0.63

Excellent

13.3

0.27

16.0

0.39

13.7

0.29

15.2

0.36

13.7

0.25

16.3

0.47

Good

72.1

0.35

71.1

0.48

72.5

0.37

70.6

0.46

72.3

0.33

70.2

0.59

Fair

12.8

0.26

11.4

0.33

12.1

0.26

12.5

0.33

12.4

0.24

11.9

0.41

Poor

1.8

0.10

1.5

0.13

1.6

0.10

1.8

0.13

1.7

0.09

1.6

0.16

Within a year

67.5

0.37

55.8

0.52

68.7

0.38

55.2

0.49

67.4

0.34

50.5

0.63

1–4 years ago

13.1

0.27

15.4

0.38

13.0

0.28

15.3

0.36

13.3

0.25

16.1

0.47

> 4 years ago

8.0

0.22

11.8

0.34

7.9

0.23

11.6

0.32

8.1

0.20

13.2

0.43

Never

11.3

0.25

17.0

0.39

10.4

0.25

17.9

0.38

11.2

0.23

20.2

0.51

No

12.7

0.29

29.5

0.48

14.4

0.29

25.3

0.44

14.4

0.27

32.4

0.60

Yes

87.3

0.29

70.5

0.48

85.6

0.29

74.7

0.44

85.6

0.27

67.6

0.60

Continued

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Vaccination
Influenza

Patients’ questioning attitude

High-risk disease
Pneumonia or influenza vaccination
History of influenza or pneumonia in the past year

Depression

Homeboundness
Social participation
Social cohesion
Reciprocity

Pneumococcal

Either (E) or neither (N)

Yes

SD

No

SD

Yes

SD

No

SD

E

SD

N

SD

Excellent

66.3

0.40

60.6

0.54

66.1

0.42

61.4

0.50

65.7

0.37

59.7

0.65

Good

22.2

0.36

24.2

0.49

22.2

0.38

23.9

0.45

22.4

0.33

24.5

0.59

Fair

6.9

0.20

9.3

0.32

7.0

0.22

8.9

0.29

7.2

0.19

9.5

0.39

Poor

4.7

0.17

5.9

0.25

4.7

0.17

5.8

0.23

4.7

0.15

6.3

0.31

No

69.5

0.36

74.0

0.46

70.0

0.37

72.7

0.44

70.1

0.33

74.3

0.56
0.56

≥1

30.5

0.36

26.0

0.46

30.0

0.37

27.3

0.44

29.9

0.33

25.7

No

24.5

0.35

32.9

0.50

19.7

0.33

60.6

0.49

-

-

-

-

Yes

75.5

0.35

67.1

0.50

80.3

0.33

39.4

0.49

-

-

-

-

No

79.3

0.34

87.9

0.37

80.4

0.37

85.3

0.41

80.5

0.31

88.3

0.44

Yes

20.7

0.34

12.1

0.37

19.6

0.37

14.7

0.41

19.5

0.31

11.7

0.44

Not applicable

79.1

0.34

77.0

0.46

80.0

0.34

75.9

0.44

79.3

0.31

75.4

0.58

Homeboundness

16.7

0.31

18.0

0.42

16.2

0.32

18.7

0.40

16.5

0.29

19.2

0.53

Depression

4.2

0.16

5.0

0.23

3.8

0.16

5.4

0.22

4.2

0.14

5.4

0.29

No

96.2

0.15

96.4

0.19

96.4

0.15

96.1

0.19

96.3

0.13

96.1

0.25

Homeboundness

3.8

0.15

3.6

0.19

3.6

0.15

3.9

0.19

3.7

0.13

3.9

0.25

No participation

62.2

0.40

63.5

0.52

60.9

0.41

65.4

0.49

61.6

0.37

65.8

0.62

≥1

37.8

0.40

36.5

0.52

39.1

0.41

34.6

0.49

38.4

0.37

34.2

0.62

No social cohesion

14.3

0.28

16.1

0.39

14.3

0.29

15.9

0.38

14.4

0.26

16.8

0.48
0.48

≥1

85.7

0.28

83.9

0.39

85.7

0.29

84.1

0.38

85.6

0.26

83.2

No reciprocity

3.4

0.16

3.5

0.20

3.3

0.16

3.6

0.21

3.2

0.14

3.9

0.26

≥1

96.6

0.16

96.5

0.20

96.7

0.16

96.4

0.21

96.8

0.14

96.1

0.26

Table 1.  Variables of participants by the status of influenza or pneumococcal vaccinations. IADL instrumental
activity of daily life, IA intellectual activity, SR social role, TMIG-IC Tokyo Metropolitan Institute ofGerontology Index of Competence. *Incapable of any one task/activity. **Incapable of any two tasks/activities.

IADL
IA
SR
TMIG-IC

Number of incapable tasks/
activities

Influenza vaccination

Pneumococcal vaccination

Neither of the two vaccinations

0

1.00 (Reference)

1.00 (Reference)

1.00 (Reference)

1*

0.93 (0.87–0.99)

1.04 (0.98–1.10)

0.97 (0.89–1.07)

2**

1.04 (0.95–1.14)

1.13 (1.05–1.23)

1.17 (1.03–1.33)

1

1.05 (1.02–1.09)

1.02 (0.99–1.06)

1.07 (1.02–1.13)

2

1.04 (0.99–1.09)

1.10 (1.08–1.12)

1.18 (1.11–1.25)

1

1.08 (1.04–1.12)

0.99 (0.96–1.03)

1.06 (1.01–1.12)

2

1.12 (1.08–1.16)

1.02 (0.98–1.06)

1.13 (1.07–1.20)

11.05 (1.004–1.09)

1.00 (0.96–1.04)

1.05 (0.99–1.12)

2

1.11 (1.07–1.15)

1.02 (0.99–1.06)

1.14 (1.08–1.21)

Table 2.  IRRs and 95% CIs of associations between non-receipt of vaccinations and IADL, IA, SR, or
TMIG-IC. IRR incident rate ratio, 95% CI 95% confidence interval, IADL instrumental activity of daily
life, IA intellectual activity, SR social role, TMIG-IC Tokyo Metropolitan Institute of Gerontology Index ofCompetence. *Incapable of any one task/activity. **Incapable of any two tasks/activities. IRRs and 95% CIs
were adjusted for age, sex, marital status, educational attainment, equivalized income, household structure,smoking status, self-rated health, medical checkup, family physician, patient’s questioning attitude, high-risk
disease, pneumonia, or influenza vaccination (only for non-receipt of influenza or pneumococcal vaccination),
history of influenza or pneumonia, geriatric depression, homeboundness, civic participation, social cohesion,and reciprocity.

activities: IRR 0.79, 95% CI 0.70–0.88; IA: for two incapable tasks/activities: IRR 0.78, 95% CI 0.73–0.83; SR:
for two incapable tasks/activities: IRR 0.83, 95% CI 0.79–0.88; TMIG-IC: for two incapable tasks/activities: IRR
0.82, 95% CI 0.78–0.87). Having a family physician was negatively associated with non-receipt of pneumococcal vaccination, regardless of incapability in IA, SR, or TMIG-IC (e.g., IA: for one incapable task/activity: IRR
0.95, 95% CI 0.90–0.99; SR: for two incapable tasks/activities: IRR 0.94, 95% CI 0.89–0.99; TMIG-IC: for two
incapable tasks/activities: IRR 0.93, 95% CI 0.88–0.99). Having a family physician was negatively associated with
non-receipt of the both vaccinations, regardless of incapability in IADL, IA, SR, or TMIG-IC (e.g., IADL: for
two incapable tasks/activities: IRR 0.72, 95% CI 0.62–0.84; IA: for two incapable tasks/activities: IRR 0.70, 95%
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Number of incapabletasks/activities

IADL

IA

SR

TMIG-ICHome physician

Influenza vaccination

Pneumococcal
vaccination

Neither of the two
vaccinations

0No

1.00 (Reference)

1.00 (Reference)

1.00 (Reference)0Yes0.73 (0.71–0.76)

0.92 (0.89–0.95)

0.58 (0.56–0.61)

1*

Yes

0.68 (0.63–0.74)

0.97 (0.90–1.04)

0.59 (0.53–0.67)

2**

Yes

0.79 (0.70–0.88)

1.07 (0.98–1.17)

0.72 (0.62–0.84)

0Yes

0.72 (0.69–0.75)

0.91 (0.88–0.95)

0.57 (0.54–0.61)

1Yes

0.76 (0.72–0.80)

0.95 (0.90–0.99)

0.63 (0.59–0.68)

2

Yes

0.78 (0.73–0.83)

0.99 (0.94–1.05)

0.70 (0.64–0.76)

0Yes

0.74 (0.70–0.77)

0.90 (0.85–0.94)

0.59 (0.54–0.63)

1Yes

0.79 (0.75–0.83)

0.89 (0.85–0.94)

0.62 (0.57–0.67)

2

Yes

0.83 (0.79–0.88)

0.94 (0.89–0.99)

0.69 (0.63–0.74)

0Yes

0.74 (0.69–0.78)

0.89 (0.84–0.95)

0.58 (0.53–0.63)

1Yes

0.77 (0.72–0.82)

0.90 (0.84–0.95)

0.60 (0.55–0.66)

2

Yes

0.82 (0.78–0.87)

0.93 (0.88–0.99)

0.68 (0.62–0.73)

Table 3.  IRRs and 95% CIs of interactions between IADL, IA, SR, or TMIG-IC and a family physician on nonreceipt of vaccinations. IRR incident rate ratio, 95% CI 95% confidence interval, IADL instrumental activityof daily life, IA intellectual activity, SR social role, TMIG-IC Tokyo Metropolitan Institute of Gerontology
Index of Competence. *Incapable of any one task/activity. **Incapable of any two tasks/activities. The IRRs
and 95% CIs were adjusted for age, sex, marital status, educational attainment, equivalized income, household
structure, smoking status, self-rated health, medical checkup, family physician, patient’s questioning attitude,high-risk disease, pneumococcal or influenza vaccination (only for non-receipt of influenza or pneumococcal
vaccination), history of influenza or pneumonia, geriatric depression, homeboundness, civic participation,social cohesion, and reciprocity.

CI 0.64–0.76; SR: for two incapable tasks/activities: IRR 0.69, 95% CI 0.63–0.74; TMIG-IC: for two incapabletasks/activities: IRR 0.68, 95% CI 0.62–0.73). A result of sensitivity analysis with the complete data set without
imputation was almost matched with the result analyzed with the imputed data sets (Supplemental Table 3).

Discussion

We investigated the association between lower capacities of higher functions in competency and non-receipt ofinfluenza, pneumococcal, or the both vaccinations among older adults aged 65 years or more. Our results showedthat the deterioration of IADL, IA, and SR was positively associated with non-receipt of influenza vaccination,that IADL and IA but not SR was positively associated with pneumococcal vaccination, and that the deterioration of all the three was positively associated with non-receipt of both the vaccinations. In addition, having afamily physician mitigated the association between the deterioration of the higher functions and non-receipt ofeach or the both vaccinations. Our results suggested that maintaining IA and SR are important to undergo thevaccinations according to the recommended schedule and that having a family physician could promote vaccination even for older adults with lower capabilities in functions.
The TMIG-IC assesses IA by asking responders whether they are capable of seeking health-related information by reading articles in the media (see Methods). Moriya et al. showed that IA was associated with general­intelligence28. This suggests that it is challenging for older adults with lower capabilities in IA to find and understand information related to vaccinations. These older adults may be less likely to receive the vaccinations because
they are not interested in and capable of understanding the media’s promotion of the risks and necessity of infectious diseases compared to normal adults. Shar et al. showed that dementia has a negative effect on influenza
vaccination among community-dwelling or institutionalized older a­ dults9. Our results show that IA is associatedwith both influenza and pneumococcal vaccinations among community-dwelling older adults. IA in the TMIGIC predicts dementia risk among functionally independent community-dwelling older a­ dults29. Taken together,
it is suggested that the lower cognitive capability before dementia may impede vaccination among older adults.
Our results show that SR is associated with two vaccinations among older adults and that the ability to playa SR is also as important for vaccinations among them. To our best knowledge, this is the first study that shows
the association between SR and vaccinations among older adults. SRs are defined as “social positions that arelinked to sets of norms, expectations, rules and behaviors a person is expected to comply with when enacting a­role30.” SRs may encourage older adults to prevent the spread of infectious diseases as members of society andcontribute to the promotion of vaccinations.
We recently showed that there are heterogeneous determinants of influenza and pneumococcal vaccinations
among older a­ dults13. Our results show that lower capability of SR was significantly associated with non-receipt
of influenza vaccination, while the association was weak with non-receipt of pneumococcal vaccination. Nicholls
et al. showed motivation to receive influenza vaccination for protecting a family member with a diminishedimmune system was greater than the one to receive pneumococcal vaccination among ­adults31. SR may be more
important to be motivated for receiving influenza vaccination to protect people living together, but it is not somuch for receiving pneumococcal vaccination among older adults because of the reason which was discussed
above. On the other hand, our results show that lower capability of IADL was associated with non-receipt of

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pneumococcal vaccination, while it was negatively associated with non-receipt of influenza vaccination, suggesting that IADL is important to receive pneumococcal vaccination than influenza vaccination and that thelower capability enhances influenza vaccination, which is opposite to our hypothesis. There may be differencein accessibility of pneumococcal and influenza vaccinations for older adults with the lower capability of IADL
because there is a difference between the two vaccinations in implemented year as the national program: theprogram for influenza vaccination started since 2001, while the one for pneumococcal vaccination did since­20147,32. However, further investigation is necessary to examine the hypothesis.
Our results show that incapability of IADL, IA, and SR were associated with non-receipt of both influenza
and pneumococcal vaccinations, while IADL or SR and IA were associated with non-receipt of influenza or
pneumococcal vaccination. Non-receipt of both the vaccinations was prevalent among older adults. Our results
suggest that all the capability of IADL, IA, and SR have an effect on both the vaccinations (24.1%) and that IADLor SR and IA have the same on influenza (16.4%) or pneumococcal vaccination (10.8%).
We and other groups have shown that having a family physician or general practitioner is positively associated with influenza and pneumococcal vaccinations among older a­ dults13,33,34. We show that having a family
physician mitigated the associations for non-receipt, suggesting that it compensated lower capabilities of IADL,
IA, and SR which are important for the vaccinations among older adults. It would be more convenient for older
adults with lower capability of IADL to receive vaccinations at the family physician’s clinic in their home town
than going to a medical facility far away by using public transport or driving a car i­ ndependently35. It would beeasier for those with lower capabilities in IA to understand the risks of the diseases and benefits of the vaccinations, with explanations by their family physician rather than seeking such information t­ hemselves28. A family
physician may increase awareness of the infection risks among older adults who are less likely to recognize therisk of transmission to or from family or friends due to decreased S­ Rs36,37.
Our results have some limitations. First, this study has a cross-sectional design, so we did not determine
causal pathways. The possibility of a reverse causal relationship between influenza, pneumococcal vaccinations,and competency of older adults potentially cannot be completely excluded; however, it is unlikely that thesevaccinations improve lower competency of older adults. Second, the nature of the observational study could notclarify causality because of unmeasured confounders. However, we have tried to adjust for major confounding
variables on the individuals and vaccinations. Third, our findings cannot be generalized to people who had beencertified as needing long-term care. Fourth, a recall bias may have occurred in the survey for the vaccinations.
The impact of this potential bias is unknown.
Vaccinations are necessary to prevent older adults from catching severe influenza and pneumonia. One reportamong older adults has shown that IADL is associated with these vaccinations. However, it remained uninvestigated whether higher-level functional capacities are associated with the vaccinations. Our results showed thatlower capabilities in IA and SR were positively associated with non- receipt of vaccinations as well as IADL
and that having a family physician mitigated the associations. Our results suggest that maintaining IA and SR
is important for older adults to receive the recommended vaccinations as scheduled and that having a family
physician to promote the vaccinations is beneficial even for older adults with limited f­ unctions14–16. This study
indicates that vaccine policies for older adults should consider the higher-level functional capacities and thebenefit of having a family physician.

Data availability

Data are from the JAGES study. All inquiries are to be addressed to the data management committee via e-mail:dataadmin.ml@jages.net. All JAGES datasets have ethical and legal restrictions on public deposition due to theinclusion of sensitive information from human participants.
Received: 14 March 2022; Accepted: 11 October 2022

References

1. Peteranderl, C., Herold, S. & Schmoldt, C. Human influenza virus infections. Semin. Respir. Crit. Care Med. 37(4), 487–500. https://​doi.​org/​10.​1055/s-​0036-​15848​01[publi​shedO​nline​First:​2016/​08/​04] (2016).
2. Paget, J. et al. Global mortality associated with seasonal influenza epidemics: New burden estimates and predictors from the
GLaMOR Project. J. Glob. Health 9(2), 020421. https://​doi.​org/​10.​7189/​jogh.​09.​02042​1[publi​shedO​nline​First:​2019/​11/​02] (2019).
3. Troeger, C. et al. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect. Dis. 18(11),1191–1210. https://​doi.​org/​10.​1016/​s1473-​3099(18)​30310-4 (2018).
4. Nichol, K. L. et al. Effectiveness of influenza vaccine in the community-dwelling elderly. N. Engl. J. Med. 357(14), 1373–1381.
https://​doi.​org/​10.​1056/​NEJMo​a0708​44 (2007).
5. La, J. et al. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N. Engl. J. Med. 348(18), 1747–1755. https://​doi.​
org/​10.​1056/​NEJMo​a0226​78 (2003).
6. Jain, A. et al. Lower vaccine uptake amongst older individuals living alone: A systematic review and meta-analysis of social determinants of vaccine uptake. Vaccine 35(18), 2315–2328. https://​doi.​org/​10.​1016/j.​vacci​ne.​2017.​03.​013[publi​shedO​nline​First:​2017/​
03/​28] (2017).
7. Kousuke Iwai-Saito, Y. S., Katsunori, K. Social capital and pneumococcal vaccination (PPSV23) in community-dwelling older
Japanese: A JAGES multilevel cross-sectional study. BMJ Open (2021) in press.
8. Chuang, Y. C. et al. Social capital and health-protective behavior intentions in an influenza pandemic. PLoS ONE 10(4), e0122970.
https://​doi.​org/​10.​1371/​journ​al.​pone.​01229​70[publi​shedO​nline​First:​2015/​04/​16] (2015).
9. Shah, S. M. et al. The impact of dementia on influenza vaccination uptake in community and care home residents. Age Ageing
41(1), 64–69. https://​doi.​org/​10.​1093/​ageing/​afr13​5[publi​shedO​nline​First:​2011/​11/​18] (2012).
10. Lawton, M. P. Assessing the competence of older people. Research Planning and Action for the Elderly: The Power and Potential ofSocial Science, 122–143 (1972).

Scientific Reports |(2022) 12:17247 |https://doi.org/10.1038/s41598-022-22192-2

7
Vol.:(0123456789)

www.nature.com/scientificreports/
11. Manias, E. et al. Associations between inappropriate medication use and (instrumental) activities of daily living in geriatric rehabilitation inpatients: RESORT study. Aging Clin. Exp. Res. https://​doi.​org/​10.​1007/​s40520-​021-​01946-​4[publi​shedO​nline​First:​
2021/​08/​10] (2021).
12. Fujiwara, Y. et al. Longitudinal changes in higher-level functional capacity of an older population living in a Japanese urban community. Arch. Gerontol. Geriatr. 36(2), 141–153. https://​doi.​org/​10.​1016/​s0167-​4943(02)​00081-x (2003).
13. Sato, K. et al. Association of pneumococcal and influenza vaccination with patient-physician communication in older adults: A
nationwide cross-sectional study from the JAGES 2016. J. Epidemiol. https://​doi.​org/​10.​2188/​jea.​JE202​00505​[publi​shedO​nline​
First:​2021/​02/​09] (2021).
14. Demicheli, V. et al. Vaccines for preventing influenza in the elderly. Cochrane Database Syst. Rev. https://​doi.​org/​10.​1002/​14651​
858.​CD004​876.​pub4 (2018).
15. Q&A on Influenza, Ministry of health labour and welfare, Japan. In Ministry of Health Labour and Welfare J, ed. Q&A on Influenza.
https://​www.​mhlw.​go.​jp/​bunya/​kenkou/​kekka​ku-​kanse​nshou​01/​qa_​eng.​html
16. Matanock, A. et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among
adults aged ≥65 years: Updated recommendations of the advisory committee on immunization practices. MMWR Morb. Mortal.
Wkly Rep. 68(46), 1069–1075. https://​doi.​org/​10.​15585/​mmwr.​mm684​6a5[publi​shedO​nline​First:​20191​122] (2019).
17. Koyano, W. et al. Measurement of competence: Reliability and validity of the TMIG Index of Competence. Arch. Gerontol. Geriatr.
13(2), 103–116. https://​doi.​org/​10.​1016/​0167-​4943(91)​90053-s (1991).
18. Ministry of health. Labor and welfare J. Ministry of health. l.a.w., Japan, comprehensive survey of living conditions, 2017 (2017)
19. Rothberg, M. B., Haessler, S. D. & Brown, R. B. Complications of viral influenza. Am. J. Med. 121(4), 258–264. https://​doi.​org/​10.​1016/j.​amjmed.​2007.​10.​040[publi​shedO​nline​First:​2008/​04/​01] (2008).
20. Yndestad, A. et al. Systemic inflammation in heart failure–the whys and wherefores. Heart Fail. Rev. 11(1), 83–92. https://​doi.​org/​
10.​1007/​s10741-​006-​9196-​2[publi​shedO​nline​First:​2006/​07/​05] (2006).
21. Burke, W. J., Roccaforte, W. H. & Wengel, S. P. The short form of the geriatric depression scale: A comparison with the 30-item
form. J. Geriatr. Psychiatry Neurol. 4(3), 173–178. https://​doi.​org/​10.​1177/​08919​88791​00400​310[publi​shedO​nline​First:​1991/​07/​01] (1991).
22. Shobugawa, Y. et al. Social participation and risk of influenza infection in older adults: A cross-sectional study. BMJ Open 8(1),e016876. https://​doi.​org/​10.​1136/​bmjop​en-​2017-​01687​6[publi​shedO​nline​First:​2018/​01/​27] (2018).
23. Saito, M. et al. Development of an instrument for community-level health related social capital among Japanese older people: The
JAGES Project. J. Epidemiol. 27(5), 221–227. https://​doi.​org/​10.​1016/j.​je.​2016.​06.​005[publi​shedO​nline​First:​2017/​02/​09] (2017).
24. Charland, K. M. et al. Socio-economic disparities in the burden of seasonal influenza: the effect of social and material deprivation
on rates of influenza infection. PLoS ONE 6(2), e17207. https://d​ oi.o​ rg/1​ 0.1​ 371/j​ ourna​ l.p​ one.0​ 01720​ 7[publis​ hedOn​ lineF​ irst:2​ 011/​
03/​02] (2011).
25. Royston, P. & White, I. R. Multiple imputation by chained equations (MICE): Implementation in Stata. J. Stat. Softw. 45(4), 1–20
(2011).
26. Zou, G. A modified poisson regression approach to prospective studies with binary data. Am. J. Epidemiol. 159(7), 702–706. https://​doi.​org/​10.​1093/​aje/​kwh09​0[publi​shedO​nline​First:​2004/​03/​23] (2004).
27. Barros, A. J. & Hirakata, V. N. Alternatives for logistic regression in cross-sectional studies: An empirical comparison of models
that directly estimate the prevalence ratio. BMC Med. Res. Methodol. 3(1), 21. https://​doi.​org/​10.​1186/​1471-​2288-3-​21 (2003).
28. Moriya, S. et al. Associations between higher-level competence and general intelligence in community-dwelling older adults. Aging
Ment. Health 17(2), 242–249. https://​doi.​org/​10.​1080/​13607​863.​2012.​71725​6[publi​shedO​nline​First:​2012/​09/​12] (2013).
29. Takeda, T., Kondo, K. & Hirai, H. Psychosocial risk factors involved in progressive dementia-associated senility among the elderly
residing at home. AGES project–three year cohort longitudinal study. Nihon Koshu Eisei Zasshi 57(12), 1054–1065 (2010).
30. Biddle, B. J. Recent developments in role theory. Ann. Rev. Sociol. 12(1), 67–92 (1986).
31. Nicholls, L. A. B. et al. Older adults’ vaccine hesitancy: Psychosocial factors associated with influenza, pneumococcal, and shingles vaccine uptake. Vaccine 39(26), 3520–3527. https://​doi.​org/​10.​1016/j.​vacci​ne.​2021.​04.​062[publi​shedO​nline​First:​2021/​05/​24](2021).
32. Sugaya, N. A review of the indirect protection of younger children and the elderly through a mass influenza vaccination programin Japan. Exp. Rev. Vaccines 13(12), 1563–1570. https://​doi.​org/​10.​1586/​14760​584.​2014.​95103​6[publi​shedO​nline​First:​20140​820](2014).
33. Dominguez, A. et al. Factors associated with pneumococcal polysaccharide vaccination of the elderly in Spain: A cross-sectional
study. Hum. Vaccines Immunothe.r 12(7), 1891–1899. https://d​ oi.o​ rg/1​ 0.1​ 080/2​ 16455​ 15.2​ 016.1​ 14966​ 1[publis​ hedOn​ lineF​ irst:2​ 016/​
04/​12] (2016).
34. Ang, L. W. et al. Factors associated with influenza vaccine uptake in older adults living in the community in Singapore. Epidemiol.
Infect 145(4), 775–786. https://​doi.​org/​10.​1017/​S0950​26881​60024​91[publi​shedO​nline​First:​2016/​12/​09] (2017).
35. Okoro, C. A. et al. Prevalence of disabilities and health care access by disability status and type among adults - United States, 2016.
MMWR Morb. Mortal. Wkly Rep. 67(32), 882–887. https://​doi.​org/​10.​15585/​mmwr.​mm673​2a3[publi​shedO​nline​First:​2018/​08/​17] (2018).
36. Higuchi, M. et al. Correlation between family physician’s direct advice and pneumococcal vaccination intention and behavior
among the elderly in Japan: a cross-sectional study. BMC Fam. Pract. 19(1), 153. https://​doi.​org/​10.​1186/​s12875-​018-​0841-​3[publi​
shedO​nline​First:​2018/​09/​07] (2018).
37. Bovier, P. A. et al. Importance of patients’ perceptions and general practitioners’ recommendations in understanding missed
opportunities for immunisations in Swiss adults. Vaccine 19(32), 4760–4767. https://d​ oi.o​ rg/1​ 0.1​ 016/s​ 0264-4​ 10x(01)0​ 0223-7​ [publi​
shedO​nline​First:​2001/​09/​06] (2001).

Acknowledgements

The authors would like to express their sincere gratitude to the staff members who conducted the surveys, allparticipants who participated in this survey, and the JAGES group members.

Author contributions

All authors (K.I.S., K.S., and K.K.) conceptualized the study and contributed to its design. K.I.S. performed thestatistical analysis under the supervision of K.S. All authors contributed to the interpretation of the data. K.I.S.
wrote the first draft of the article, which was revised critically by K.S. and K.K. for important content. All authors
have read and agreed to the published version of the manuscript.

Funding

This study was supported by Grant-in-Aid for Scientific Research (15H01972, 15H04781, 15H05059,
15K03417, 15K03982, 15K16181,15K17232, 15K18174, 15K19241, 15K21266, 15KT0007, 15KT0097,
16H05556, 16K09122, 16K00913,16K02025, 16K12964, 16K13443, 16K16295, 16K16595, 16K16633,
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www.nature.com/scientificreports/
16K17256, 16K17281, 16K19247,16K19267, 16K21461, 16K21465, 16KT0014, 17K04305, 17K04306, 25253052,
25713027, 26285138,26460828, 26780328, 18H03018, 18H04071, 18H03047, 18H00953, 18H00955, 18KK0057,
19H03901,19H03915, 19H03860, 19K04785, 19K10641, 19K11657, 19K19818, 19K19455, 19K24060,
19K20909,20H00557, 21K10323) from the JSPS (Japan Society for the Promotion of Science); Health Labour
Sciences Research Grants (H26-Choju-Ippan-006, H27-Ninchisyou-Ippan-001 H28- Choju-Ippan-002, H28Ninchisyou-Ippan-002, H30-Kenki-Ippan-006, H29-Chikyukibo-Ippan-001, H30-Jyunkankinado-Ippan-004,
19FA1012, 19FA2001,21FA1012, 21K19635), Research project on health and welfare promotion for the elderly
from the Ministry of Health, Labour and Welfare, Japan; the Research and Development Grants for Longevity
Science from Japan Agency for Medical Research and development (AMED) (JP18dk0110027, JP18ls0110002,
JP18le0110009, JP20dk0110034, JP21lk0310073, JP21dk0110037), the Research Funding for Longevity Sciencesfrom 47 National Center for Geriatrics and Gerontology (24-17, 24-23, 29-42, 30-30, 30-22, 20-19, 21-20); Open
Innovation Platform with Enterprises, Research Institute and Academia (OPERA, JPMJOP1831) from the Japan
Science and Technology (JST); a grant from the Japan Foundation For Aging And Health (J09KF00804), a grantfrom 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, a grant from Meiji,
Obirin University, and Niimi University (1915010). The views and opinions expressed in this article are those of
the authors and do not necessarily reflect the official policy or position of the respective funding organizations.

Competing interests

The authors declare no competing interests.

Additional information

Supplementary Information The online version contains supplementary material available at https://​doi.​org/​
10.​1038/​s41598-​022-​22192-2.
Correspondence and requests for materials should be addressed to K.I.-S.
Reprints and permissions information is available at www.nature.com/reprints.
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