Japanese Journal of Social Welfare, 60 (5), 1–12 2020

Original Article

Eﬀects of Household Composition on Health-Related Qualityof Life among the Japanese Middle-Aged and Elderly:
Analysis from a Gender Perspective
Takashi Kawano1, *, Goro Moriki1, Shinya Bono1, Nobuyuki Kaji1 and Hungu Jung2
1
2

Hiroshima Bunka Gakuen University, Hiroshima, Japan
Hiroshima Bunka Gakuen Two-Year College, Hiroshima, Japan

Abstract To elucidate the social characteristics of eligible elderly people for community-based
integrated support, we analysed the eﬀects of gender, age, household composition, employment
status, and community involvement on health-related quality of life (HRQOL) among the middleaged and elderly. We gave a questionnaire to 1020 middle-aged and elderly people in the city of A,
Hiroshima in cooperation with the local residentsʼ associations (982 responded, the respond rate:
96.3%). 720 were accepted as subjects of this study. HRQOL scores were evaluated by the Japanese Medical Outcomes Study 36-Item Short-Form Health Survey Version II. Stepwise multiple
regression analysis with HRQOL scores as a dependent variable, while controlling for age, household composition, employment status, exercise habits and community involvement, revealed thathousehold composition is a signiﬁcant predictor of physical component summary (PCS) and role/social component summary (RCS). Furthermore, one factorial analysis of variance was performed
to evaluate HRQOL scores by each type of household composition, indicating that PCS and RCSof middle-aged and elderly female single-person households were signiﬁcantly lower than middleaged and elderly female in the other household types and male. Consequently, our study demonstrates that household composition is an eﬀective social factor for screening of the target elderly ofcommunity-based integrated support, and the necessity to consider social support which meets theneeds of elderly female who live alone.
Key words: living alone, the elderly, female, social isolation, health-related quality of life, community-based integrated support

I.

Introduction

According to the latest World Health Organization report (2018), the average life expectancyof Japanese women is 86.99 years, and that ofmen is 80.75 years, whereas the average healthy
life expectancy of women is 76.9 years and thatof men is 72.6 years. Japan has one of the high* Correspondence address: Hiroshima Bunka Gakuen
University, 3–3–20 Heiseigahama, Sakacho, Aki-gun,
Hiroshima, 731–4312, Japan.
E-mail: kawano@hbg.ac.jp(Received May 7, 2019; Accepted August 13, 2019)

est overall life expectancies among nations, but
in terms of quality of life (QOL), self-rated
health status of Japan is known to be relatively
low amongst the developed countries (OECD,2016). Self-rated health has been shown to serveas an eﬀective predictor of mortality rate and forthe necessity of healthcare. DeSalvo et al. (2005)
argues that people who answered ʻpoorʼ for selfrated health have a risk of mortality twice greaterthan those who chose ʻexcellentʼ.
QOL is an ambiguous concept. It can be distinguished in two categories; health-related QOL(HRQOL) includes physical, psychological,

2

T. Kawano, G. Moriki, S. Bono, N. Kaji and H. Jungsocial, spiritual state, role function and overall
well-being; and non-health-related QOL(NHRQOL) includes environment, economy andpolitics (Doi, 2004).
Several studies on HRQOL among the elderly
have suggested that not only intervention ofphysical activity improves their QOL, but alsoestablishing regular exercise increases preventive
eﬀects. That is, regular physical activities prevent chronic diseases, decreases mortality rate,and have positive eﬀects on QOL (Paﬀenbarger
et al., 1986: Stiggelbout et al., 2004). It alsoameliorates depression, and regains strength andabilities to perform daily living (Asai et al.,2001). Furthermore, establishing regular exercise
enhances physical function and self-rated healtheven for frail elderly people (Chou et al., 2012),
and prevents from developing disorders inducedby aging and disease (Tak et al., 2013)
In reality, however, there are elderly people
who do not participate in physical exercise, andlack social relationships in addition to their poor
health condition. Thus, studies have been conducted to reveal social factors by analysing
NHRQOL among the elderly with health risks interms of prevention of diseases and disorders.
House et al. (1988) focus on social relationships
as the dependent variable to determine the linkage with health. Furthermore, Gouda et al.
(2012) discuss the characteristics of people whoare isolated from the society, which are such asadvanced age, low socioeconomic status, poor
self-rated health, and lack of moral support.
Steptoe et al. (2013) distinguish loneliness fromsocial isolation, pointing out that although bothfactors are closely associated with the deterioration in QOL and increase in mortality rate, theinﬂuences of loneliness are limited, but social
isolation should be the target to be reduced.
However, since social isolation is a diﬃcult measure to quantify including NHRQOL, intervention programmes with no evaluation built into at
inception are ﬂawed with issues of reliability,
adequacy and practicality (Findlay, 2003).
For these studies on QOL among the elderly,
the key issue, both traditional and contemporary,is the problem of health and social isolation
among the elderly who live by themselves. In
Japan, signiﬁcant changes in household composition have taken place in the last 30 years, inwhich the proportion of single-person households increased from 10.7 to 26.3% between
1980 and 2015. According to the Cabinet Oﬃce,
Government of Japan (2017), as focused onhouseholds of older adults, 1 in 5 elder female
and 7 elder male of over 65 years of age live
alone in Japan. It is highlighted that the elderly
who live alone may not receive social support,
aggravate their economic state, and increase propensity to frail condition and dementia (Bilotta etal., 2010; Arslantas et al., 2015). They are perceived as at high risk in need of social support
not only in the medical ﬁeld but also in the ﬁeldof social work.
Household composition is a social factor
whose information can be obtained relatively
easily, compared to other factors, concerning
community-based integrated support, which isdeveloped by a public-private partnership. Studies on social work generally focus on the interactions between individuals and their surrounding
environments, and tend to treat household composition as a subject of studies on NHRQOL.
However, issues of social work studies such asreliability remain a challenge in the developmentof its unique measurement indices (Kubota et al.,2006). Support for elderly peopleʼs sustainablecommunity life is an important issue not only incommunity partnerships but also in social work
(McCallion et al., 2016). In complex and individualized community life support, a thorough biopsychosocial assessment is a prerequisite forsocial work intervention (Mcinnis-Dittrich,2016). Therefore, the use of HRQOL, which isestablished as a reliable measurement, is of agreat signiﬁcance for community-based integrated support, where a partnership of various
professions is required.
Previous studies on the relationships between
household composition in Japan and HRQOL
have focused speciﬁcally on single-personhouseholds, but they were without a comparison

Household Composition on HRQOL among the Japanese Middle-Aged and Elderlyof gender (Matsumoto et al., 2001; Akamine etal., 2006) or focused sorely on female (Omori,2007). Considering that women have longer life
expectancy and the number of women who
remain unmarried has increased, the period thatthey live alone gets longer, which potentiallyaﬀect their HRQOL. However, to our knowledge, no studies have investigated the gender differences in single-person households with thecomprehensive measurement of HRQOL.
To elucidate social characteristics of the eligible older adults for social support, this study
explores how household composition and gender
diﬀerences aﬀect the HRQOL among the elderly.
II.

Methods

1.

Participants
We gave a questionnaire to the middle-aged
and the elderly who live in the city of A, Hiroshima. The brieﬁng was held for the chairmen of
the residentsʼ association from each district of thecity. 10 copies of questionnaire were distributed
to each 102 chairman who gave consent to theircooperation in our research. We requested eachchairman to distribute the questionnaire to 10
people of the middle-aged and elderly in their
Table 1

district. As a result, 982 out of 1020 people intotal responded (the response rate: 96.3%). 262
were excluded from the study, who did not ﬁll in
more than one question. Consequently, 720 people were accepted as subjects for this study(Table 1).
2.

Surveyed items
The survey items of our questionnaire are gender, age, household composition, employment
status and health-related quality of life
(HRQOL). The response choices for householdcomposition are 1) single-person household, 2)household of a married couple, and 3) otherhousehold type. We employed the Japanese Medical Outcomes Study 36-Item Short-Form Health
Survey Version II (SF-36) to analyse HRQOL,
which is widely used for analyses of health of theelderly. SF-36 consists of 36 items that measure
the HRQOL during the four-week period prior to
the application of the questionnaire, by means ofeight scales or dimensions.
Physical functioning (PF)Role-physical (RP)
Limitations caused by physical problems andbodily pain (BP)General Characteristics of ParticipantsAge (years)
Household composition
Single-person
Married couple
Other
Employment status
Unemployed
Employed
Exercise habitNo
YesCommunity involvement
No
Yes

Total (N＝720)

Male (N＝198)

Female (N＝522)

68.8±0.368.2±0.769.1±0.4

154 (21%)317 (44%)249 (35%)

16 (8%)108 (55%)
74 (37%)138 (26%)
209 (40%)
175 (34%)437 (61%)283 (39%)

97 (49%)101 (51%)

340 (65%)
182 (35%)403 (56%)317 (44%)106 (54%)
92 (46%)297 (57%)
225 (43%)286 (40%)434 (60%)

90 (45%)108 (55%)

196 (38%)326 (62%)

Data are expressed as Mean ± SE values.

34

T. Kawano, G. Moriki, S. Bono, N. Kaji and H. Jung

Social functioning (SF)General health perceptions (GH)Vitality (VT)Role-emotional (RE)
Limitations caused by emotional problems andmental health (MH)Each scale measured by this instrument has atransformed score ranging from 0 to 100, where
higher ﬁgures denote a better health-related quality of life. Three standardised summary scores
can also be calculated from the subscales, allowing further analysis: physical component summary (PCS); mental component summary(MCS); and role/social component summary(RCS). We requested to register for use of SF-36
and obtained the license from the iHope International which hold its license.
3.

Statistical analysis
Each subscale and summary score of SF-36
were calculated based on the Japanese standard
values (Fukuhara, 2004) to determine a meanvalue and standard error. To investigate factors
aﬀecting HRQOL scores (PF, RP, BP, SF, GH,
VT, RE, MH, PCS, MCS, and RCS), we carriedout stepwise multiple regression analysis. The
model used HRQOL scores as the dependent
variable, while controlling for age, householdcomposition, employment status, exercise habits,
and community involvement. Furthermore, one
factorial analysis of variance (ANOVA) was performed to evaluate mean diﬀerences in HRQOL
scores of which household composition was asigniﬁcant predictor across the three groups ofhouseholds; single-resident household, household of a married couple, and the other household types. Subsequently, the Bonferroni correction was applied as post hoc test. For the
analysis, p＜0.05 was considered statisticallysigniﬁcant. All data were evaluated with SPSS
version 24.0.
4.

Ethical approval
This study was designed in compliance withthe ethical guidelines for social welfare researchof the Society. Furthermore, it was approved by
the Research Ethics Committee of Hiroshima
Bunka Gakuen University.
III.

Results

Table 2 demonstrates HRQOL scores of whichhousehold composition was a signiﬁcant predictor from the results of stepwise multiple regression analysis, extracting PF, RP, RE, PCS and
RCS. Furthermore, the results showed that age
was the most signiﬁcant inﬂuential factor forthese HRQOL scores. Older years of age weresigniﬁcantly associated with a greater decline in
HRQOL. As seen in Table 2, we extracted exercise habits as a predictor of HRQOL scores
except for RCS, indicating that exercise habits
increased HRQOL scores. It demonstrated thathousehold composition had a similar inﬂuence
on HRQOL to exercise habits for PF, RP, and
RE. Furthermore, RCS was closely associatedwith only age and household composition.
Our results from the stepwise regression analysis showed that household composition aﬀected
PF, RP, RE, PCS, and RCS, we, therefore, analysed HRQOL within each household structure.
Figure 1 compares the mean diﬀerences of
HRQOL scores across the three groups (singleresident household, household of a married couple, and other household types). The dotted lineon the value 50 of HRQOL scores indicates thestandard value for the Japanese. Single-resident
households were signiﬁcantly lower in PF, RP,
RE, PCS and RCS, compared to households of amarried couple and the other types of household.
The analysis also showed a signiﬁcant diﬀerence
between people in single-person households andhouseholds of a married couple in VT. Whereas,
there was no signiﬁcant diﬀerences between
households of a married couples and the otherhouseholds.
198 men and 522 women in single-personhouseholds were participated in this study. In
order to reveal diﬀerences between men andwomen, we analysed PF, RP, RE, PCS and RCSscores by gender. Figure 2 shows a comparison

1.991− 0.471
3.231

B

0.078

1.812

50.354 (0.000)***45.747 (0.000)***− 0.306 − 8.556***0.120
3.361**

0.351 (0.123)

1.974*− 0.3462.997

t0.401 (0.161)

0.069− 0.361 − 10.301***
0.136
3.961***

β

RCS

PCS

2.004*

2.672**

40.198 (0.000)***

B

0.091

63.344 (0.000)***βt− 0.346 − 8.709***0.102
2.941**

2.065− 0.4312.800

β0.428 (0.184)

Age
Householdcomposition

Age
Householdcomposition
Exercisehabitsemployment
statusB

RP

0.458 (0.210)t

3.600***

0.122

3.771

t

− 0.392 − 11.537***0.156
4.703***

β− 0.548
3.983
Age
Householdcomposition
Exercisehabitst0.420 (0.177)

0.111

3.269**− 0.354 − 10.207***
0.142
4.102***

β51.246 (0.000)***2.394− 0.419
3.715

B

RE

PF: Physical functioning, RP: Role physical, RE: Role emotional, MH: Mental health, PCS: Physical component summary, RCS: Role/Social component summary.

***: p＜.001, **: p＜.01, *: p＜.05

Age
ExercisehabitsHouseholdcomposition
Multiple correlationcoeﬃcient (R2)
F (p value)

Multiple correlationcoeﬃcient (R2)
F (p value)

Age
ExercisehabitsHouseholdcomposition

B

PF

Table 2 The Results of Multiple Regression Analysis in Which HRQOL as the Dependent Variable, Age, Household Composition, Employment Status, Exercise Habits, andCommunity Involvement as the Independent Variables
Household Composition on HRQOL among the Japanese Middle-Aged and Elderly
56

T. Kawano, G. Moriki, S. Bono, N. Kaji and H. Jung

HRQOL Scores Compared by Household Composition Respectively (N＝720)
Data are expressed as Mean±SE values, ***: p＜.001, **: p＜.01, *: p＜.05.
Figure 1

PF: Physical functioning, RP: Role physical, BP: Bodily pain, GH: General health, VT: Vitality, SF: Social functioning,
RE: Role emotional, MH: Mental health, PCS: Physical component summary, MCS: Mental component summary, RCS:
Role/Social component summary.

HRQOL Scores Compared by Household Composition Respectively (Male, N＝198)
Data are expressed as Mean±SE values, *: p＜.05.
Figure 2

PF: Physical functioning, RP: Role physical, BP: Bodily pain, GH: General health, VT: Vitality, SF: Social functioning,
RE: Role emotional, MH: Mental health, PCS: Physical component summary, MCS: Mental component summary, RCS:
Role/Social component summary.

Household Composition on HRQOL among the Japanese Middle-Aged and Elderly

7

HRQOL Scores Compared by Household Composition Respectively (Female, N＝522)
Data are expressed as Mean±SE values, ***: p＜.001, **: p＜.01, *: p＜.05.
Figure 3

PF: Physical functioning, RP: Role physical, BP: Bodily pain, GH: General health, VT: Vitality, SF: Social functioning,
RE: Role emotional, MH: Mental health, PCS: Physical component summary, MCS: Mental component summary, RCS:
Role/Social component summary.

of mean diﬀerences in the HRQOL scores acrossthe three groups for male participants (N＝198,
age: 68.2±0.7 years). There was a signiﬁcantdiﬀerence between households of only a couple
and the other households in GH and MCS scales,
but not between single-person households andthe other two groups. The analysis also demonstrated no signiﬁcant diﬀerences across the threegroups in the other HRQOL scales.
Figure 3 compares the diﬀerences of the meanscores of HRQOL across the three groups of thefemale subjects (N＝522, age: 69.1±0.4 years).
PF, RP, RE, PCS and RCS scales were considerably lower in the single-resident households thanthe comparison groups. The mean scores indicated signiﬁcant diﬀerences in VT and SF shown
only between single-resident households and thehouseholds of a married couple. Consequently,
HRQOL scores among women in single-personhouseholds were considerably lower than womenin the other households. Additionally, the scoresof single-person households of women wereremarkably lower than those of men.
IV.

Discussion

1. Household composition and social isolation
To elucidate the social characteristics of eligible people for community-based integrated support, we analysed how household compositioninﬂuenced HRQOL among older adults. Our
analysis demonstrates that, the PF, RP, RE, PCS
and RCS scores are signiﬁcantly low in the single-person household group. This ﬁnding corroborates a previous study highlighting that HRQOL
among elderly single-person households remains
poor compared to the elderly in other household
types (Akamine et al., 2006; You et al., 2006).
Bilotta et al. (2010) discuss the causes negatively aﬀecting QOL among the elderly one-person households. They are less likely to receive
social care, socially and economically frail, andat risk of developing depression and dementia

8

T. Kawano, G. Moriki, S. Bono, N. Kaji and H. Jung

without being examined by a specialist. Kubo etal. (2004) also report the characteristics of theelderly who live alone comparing to the elderlyin other household types, that they do not
involve in community activities, are likely tostay home, and their physical functions are signiﬁcantly low. Furthermore, the elderly living
alone in rural areas score signiﬁcantly low in
QOL compared to those who live in urban areas,
which oﬀer more social interactions. (Savikko etal., 2005: Lin PC et al., 2008). Consequently, theﬁndings of this study support Bilotta et al. (2010)
and Arslantas et al. (2015) who express that theelderly who live alone are considered to carryhigh risks.
Meanwhile, several studies have used social
isolation as a social risk factor, which is a morecomprehensive concept than household composition, to explore how a sense of loneliness and apresence or absence of social interactions aﬀect
the issues of ADL, self-rated health, chronic diseases, and depression of the elderly (Lund et al.,2010; Saito et al., 2010; Kimberley et al., 2018).
In this study trend, Holt-Lunstad et al. (2010)
suggest to utilize the concept of social isolation
as a complex measure, since the inﬂuence ofhousehold composition is limited for meta analysis to investigate the association between social
isolation and mortality risk.
In Japan, Shimada et al. (2014) report that thepercentage of social isolation emerging from single-resident households is 31%, while fromhouseholds consisted of two or more people is
24.1% in Japan, demonstrating that the likelihood of social isolation in Japan is higher thanthe West countries. Furthermore, previous studies have focused on the East Asia conducted by
Okamoto (2000) and You et al. (2006) illustratethat physical interactions such as living together
and having conversations with family increase
HRQOL. Kobayashi et al. (2011) suggest in theirstudy on lifestyles of Japanese elderly people
that when the two social factors of single-personhousehold and social isolation overlap, the speciﬁc risks become greater: the diﬃculties inreceiving support privately; nowhere to consult

with; no knowledge of community-based integrated support centre; increased propensity todepression; and a feeling of insecurity for the
future. According to the study on the JapaneseLong-Term Care Insurance System using thedata of invoice conducted by Lin HR et al.
(2017), although taking simply a single-personhousehold as a social factor is not a risk factor
leading to an increase in the levels of nursing
care, the single-person household factor for
women with dementia elevates the level of longterm nursing care needs.
The analyses from the previous and present
studies demonstrate that since household composition is a survey item inﬂuenced socially andculturally, it is conceivable that household composition is an eﬀective social factor for screeningof eligible people for social support in Japan.
2. HRQOL among elderly female singleperson households
Our study has shown that HRQOL was signiﬁcantly worse among elderly women than elderlymen. This ﬁnding provides an evidence to support the previous studies indicating the low
HRQOL among elderly female as a social problem (Rahman et al., 2000; Orﬁla et al., 2006; Van
Minh et al., 2010; Nguyen et al., 2018). In addition to the gender diﬀerences, these studies
explore other factors which decrease HRQOL,
such as chronic diseases, depression, low levels
of income and education. Furthermore, GuallarCastillón et al. (2005) claim that lifestyle, obesity, and lower levels of schooling are the factors
may explain a substantial part of the diﬀerences
between women and men in certain HRQOL
dimensions, suggesting that these factors arepotentially improved by intervention.
One of the key ﬁndings of this study reveals
that PCS and RCS scores among elder women
living alone, in particular, have been shown to besigniﬁcantly lower. This result, highlighting thatthe two factors of advanced age and single-person household are closely associated with anincrease in health risk among women, is an
important perspective to explore methods ofHousehold Composition on HRQOL among the Japanese Middle-Aged and Elderlyintervention. Taniguchi et al. (2013) argue that
self-rated health and the amount of physicalactivity (the frequency of going outdoors)
increase PCS scores, whereas chronic diseases
and lack of mutual assistance with neighbours
are closely associated with a decrease in PCS.
PCS is a summary score calculated from PF, BP,
GH and RP, focused on physical functions.
Therefore, it is necessary to investigate methodsof intervention in terms of the amount of physical activity and exercise intensity. Brown et al.
(2000) suggest that light and moderate intensityof physical exercise is closely associated with
HRQOL scores with positive eﬀects on womenat any age. Furthermore, Battaglia et al. (2016)
conducted a study an 8-week adapted physicalactivity (APA) intervention programme toelderly femaleʼs physical abilities, resulting in asigniﬁcant improvement in PF, BP, MH, PCS andMCS. Egami et al. (2009) also demonstrate thatthe group over 60 years of age who take regularexercise maintains satisfactory scores in PF andBP, arguing that exercise habits aﬀect signiﬁcantly. Comparing HRQOL among elderly
women who performed high-intensity exercise
and those who had always been sedentary havereported, it was concluded that high-intensity
exercise reduced happiness among older women(Lee et al., 2003). Consequently, it is suggested
that a balance between exercise intensity andhappiness should be taken into consideration.
RCS is a summary score calculated from RP,
SF and RE, focused on social functions. Therefore, it is essential to consider methods of intervention from the following points of view: social
relationships; morale; independence of action;and self-esteem. Gallegos-Carrillo et al. (2009)carried out a study on the relationship between
components of social networks and HRQOL
among Mexican older adults with depressive
symptoms, demonstrating that relationships withclose relatives are positively associated with PF,
BP, and SF, and networks with friends generate apositive impact on PF and RP. Furthermore, Onishi et al. (2006) report that the ﬁndings from anexperiment of recreational activity interventions

9

reveal a close relationship between the activity ofsmall group and the morale and satisfaction
scores. Additionally, the results of multiple
regression analysis show that happiness is
closely associated with joy of exercise, modest
registration fee, and enjoyment of watching TV.
Yoshii et al. (2005) conducted a follow up
research on the association between social relationships and long-term nursing-care, and suggest that the active involvement of older adults inhelping other elder people who need care potentially decreases risks of developing long-term
nursing care. Furthermore, Takehara et al. (2009)
suggest that housework is a beneﬁcial way toenrich individual lives and maintain a certain
amount of physical activity. Consequently, basedon these analyses, it is of critical importance toestablish social support which meets the needs ofthe elderly in home care, day care, and preventive care. Majority of elderly need communitybased services to continue living in their own
homes and communities (Lehning, 2018). Especially, social workers in community-based integrated care centers are expected to develop that
service and community.
3.

Limitation
However, there is a limitation to our study. We
did not include survey items relating to factors
which may aﬀect HRQOL among elderly singleperson households, such as educational level,income status and social capital. Consequently,
however, this study yielded the strong link
between HRQOL among elderly women and single-person households by narrowing the survey
items. We are planning further study to examine
NHRQOL focusing on other factors, such associal capital.
Community-based integrated support is required
to tackle to develop a community which allows
all the local residents to live for a very long time.
Social workers are mediators connecting diﬀerent
professions in the community development. In
terms of preventive care, investigating evidencebased social support with the use of HRQOL, likeour study, is of great signiﬁcance.

10

T. Kawano, G. Moriki, S. Bono, N. Kaji and H. Jung

V.

Conclusion

Our study has analysed household composition, which aﬀects HRQOL among the elderly,
and underscored the following: 1) HRQOL
scores among elderly single-resident households
are signiﬁcantly lower than elderly households ofa married couple and the other household types;
2) HRQOL scores of elderly female are considerably worse than elderly male; 3) Elderly women
who live alone have a tendency to experience a
decline in physical and social functions; 4) Single-resident households are closely associatedwith social isolation, which pose high risks; 5)Interventions of physical exercise and recreational support adapted to the physical functions
and psychological state of elderly female singleperson households may lead to improve their
HRQOL.
Acknowledgements
This study summarizes part of a research study
conducted under a Grant-in-Aid for Private University Research Branding Project of the Ministry of Education, Culture, Sports, Science andTechnology (MEXT). We would like to express
our deeply grateful to all those involved in thisquestionnaire.
References
Akamine I, Shinjo M (2006). Support for elderly people
living in a community: Focus on elderly people living
alone. Japanese Journal of Health and Human Ecology
72(5): 191–207. (in Japanese and English abstract)
Abacigil Ergin F, Adana F, Arslantas H, et al. (2015).
Loneliness in elderly people, associated factors and its
correlation with Quality of Life: A ﬁeld study fromwestern Turkey. Iranian Journal of Public Health 44(1):43–50.
Asai H, Ido E, Shinkai S, et al. (2001). Eﬀectiveness of
exercise training for a short period on QOL for theelderly living in a home for the aged. Japan Journal of
Physical Education Health and Sport Sciences 46(3):269–279. (in Japanese and English abstract)
Alesi M, Battaglia G, Bellaﬁore M (2016). Eﬀects of an
adapted physical activity program on psychophysicalhealth in elderly women. Clinical Interventions inAging 11: 1009–1015.
Avlund K, Lund R, Nilsson CJ (2010). Can the higher
risk of disability onset among older people who live
alone be alleviated by strong social relations?: A longitudinal study of non-disabled men and women. Ageand Ageing 39(3): 319–326.
Banegas JR, Guallar-Castillón P, Redondo Sendino Á, etal. (2005). Diﬀerences in quality of life between
women and men in the older population of Spain.
Social Science & Medicine 60(6): 1229–1240.
Bilotta C, Case A, Nicolini P, et al. (2010). Social vulnerability, mental health and correlates of frailty in older
outpatients living alone in the community in Italy.
Aging & Mental Health 14(8): 1024–1036.
Brown WJ, Lee C, Mishra G (2000). Leisure time physical activity in Australian women: Relationship with
wellbeing and symptoms. Research Quarterly for Exercise and Sport 71(3): 206–216.
Byass P, Thi Kim Chuc N, Van Minh H, et al. (2010). Patterns of health status and quality of life among older
people in rural Viet Nam. Global Health Action 3(1):2124.
Cabinet Oﬃce, Government of Japan (2017). Annual
report on the aging society.
Chou CH, Hwang CL, Wu YT (2012). Eﬀect of exercise
on physical function, daily living activities, and qualityof life in the frail older adults: A meta-analysis.
Archives of Physical Medecine and Rehabilitation
93(2): 237–244.
Chorus A, Kuiper R, Tak E, et al. (2013). Prevention of
onset and progression of basic ADL disability by physical activity in community dwelling older adults: A
meta-analysis. Ageing Research Reviews 12(1): 329–
338.
DeSalvo KB, Fan VS, McDonell MB, et al. (2005). Predicting mortality and healthcare utilization with a single question. Health Services Research Journal 40(4):1234–1246.
Doi Y (2004) Introduction-conceptual issues on Qualityof Life (QOL) and importance of QOL research. Journal of the National Institute of Public Health 53(3):176–180. (in Japanese and English abstract)
Egami E, Kenjoh M, Moriya H, et al. (2009). The relationship between exercise habit and health indexes ofthe people using a health promotion facility. Journal ofJapan Society of Nursing Research 32(1): 69–78. (inJapanese and English abstract)
Ferrer M, Lamarca R, Orﬁla F, et al. (2006). Gender differences in health-related quality of life among theelderly: The role of objective functional capacity andchronic conditions. Social Science & Medecine 63(9):2367–2380.
Fetzer SJ, Lin PC, Yen M (2008). Quality of life in elders
living alone in Taiwan. Journal of Clinical Nursing
17(12): 1610–1617.

Household Composition on HRQOL among the Japanese Middle-Aged and Elderly
Findlay RA (2003). Interventions to reduce social isolation amongst older people: Where is the evidence?
Ageing & Society 23(5): 647–658.
Fukuhara S, Suzukamo Y (2004). Manual of SF-36v2
Japanese version: Institute for Health Outcomes & Process Evaluation Research, Kyoto.
Fujiwara Y, Kobayashi E, Saito M, et al. (2010). Prevalence and characteristics of social isolation in theelderly in a dormitory suburb according to householdcomposition. Nihon Koshu Eisei Zasshi 57(9): 785–
795. (in Japanese and English abstract)
Gallegos-Carrillo K, Mudgal J, Sánchez-García S, et al.
(2009). Social networks and health-related quality oflife: A population based study among older adults.
Salud Pública de México 51(1): 6–13.
Gouda K, Okamoto R (2012). Current status of and factors associated with social isolation in the elderly living
in a rapidly aging housing estate community. Environmental Health and Preventive Medicine 17(6): 500–
511.
Holt-Lunstad J, Layton JB, Smith TB, et al. (2010).
Social relationships and mortality risk: A meta-analytic
review. PLOS Medicine 7(7), e1000316.
Hopman-Rock M, Popkema DY, Stiggelbout M, et al.
(2004). Once a week is not enough: Eﬀects of a widely
implemented group based exercise programme forolder adults: A randomised controlled trial. Journal of
Epidemiology and Community Health 58(2): 83–88.
Hoshino A, Katsura T, Taniguchi N, et al. (2013). Comparison of QOL factors between so-called ʻyounger oldʼand ʻolder oldʼ community residents. Journal of the Japanese Association of Rural Medicine 62(2): 91–105. (inJapanese and English abstract)
House JS, Landis KR, Umberson D (1988). Social relationships and health. Science 241(4865): 540–545.
Hyde R, Paﬀenbarger Jr RS, Wing AL, et al. (1986).
Physical activity, all-cause mortality, and longevity ofcollege alumni. The New England Journal of Medecine314(10): 605–613.
Imanaka Y, Lin HR, Otsubo T (2017). Survival analysis
of increases in care needs associated with dementia andliving alone among older long-term care service users
in Japan. BMC Geriatrics 17(1): 182.
Kimberley J, Christina V (2018). Typologies of loneliness, living alone and social isolation, and their associations with physical and mental health. Ageing & Society. Published online: 10 April 2018.
Kobayashi E, Fujiwara Y, Fukaya T, et al. (2011). Social
support availability and psychological well-being
among the socially isolated elderly diﬀerences by living arrangement and gender. Nihon Koshu Eisei Zasshi
58(6): 446–456. (in Japanese and English abstract)
Kondo K, Kuze J, Yoshii K, et al. (2005). Social relationship factors and risk of care requirement in Japaneseelderly, Nihon Koshu Eisei Zasshi 52(6): 456–467. (in11Japanese and English abstract)
Kubo A, Kamijo K, Murata S, et al. (2014). Large scale
survey on the characteristics of alone elderly and nonalone elderly. Japanese Journal of Health and Welfare
Statistics 61(11): 21–26. (in Japanese)
Kubota A, Hatano Y (2006). Importance of QOL studies
in social welfare (documentary study). Japanese Journal of Social Welfare 47(3): 43–51. (in Japanese andEnglish abstract)
Lee C, Russell A (2003). Eﬀects of physical activity on
emotional well-being among older Australian women:cross-sectional and longitudinal analyses. Journal of
Psychosomatic Research 54(2): 155–160.
Lehning AJ (2018). Policies related to home-and community-based services. Home-and community-based services for older adults: Aging in context, pp. 12–30.
New York, Columbia University Press.
Liu J, Rahman MO (2000). Gender diﬀerences in functioning for older adults in rural Bangladesh: The
impact of diﬀerential reporting? Journal of Gerontology A Biological Sciences and Medical Sciences,55(1): 28–33.
Masuda Y, Onishi J, Suzuki Y, et al. (2006). The pleasurable recreational activities among community-dwellingolder adults. Archives of Gerontology and Geriatrics
43(2): 147–155.
Matsumoto K, Tojo M (2001). A study on the relations
between mental well-being and social supports for theelderly people living alone. Japanese Journal of Human
Sciences of Health-Social Services 7(2): 81–89. (inJapanese and English abstract)
McCallion P, Hooyman N (2016). Social Work Practice in
the Community. The Oxford Handbook of Social Workin Health and Aging, pp. 91–96. New York, Oxford
University Press.
Mcinnis-Dittrich, K (2016). Comprehensive Biopsycosocial Assessments: The Foundation of Social Work Practice with Older Adults. The Oxford Handbook of Social
Work in Health and Aging, pp. 9–17. New York,
Oxford University Press.
Nguyen TT, Le NB, Vu LH (2018). Quality of life and its
association among older people in rural Vietnam. Quality & Quantity 53(1): 131–141.
Nakano K, Shimada K, Yamazaki S, et al. (2014). Prevalence of social isolation in community-dwelling elderly
by diﬀerences in household composition and related
factors: From a social network perspective in urban
Japan. Journal of Aging and Health 26(5): 807–823.
OECD (2016). Japan: Boosting Growth and Well-being inan Ageing Society. OECD Paris.
Okamoto K (2000). Feeling of well-being and family
contacts in community elderly residents. Japanese
Journal of Geriatrics 37(2): 149–154. (in Japanese andEnglish abstract)
Omori J (2007). Correlation between interactions of

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T. Kawano, G. Moriki, S. Bono, N. Kaji and H. Jung

younger elderly women with close non-family friends
and neighbors and health-related QOL. Nihon Koshu
Eisei Zasshi 54(9): 605–614. (in Japanese and English
abstract)
Routasalo P, Savikko N, Tilvis RS, et al. (2005). Predictors and subjective causes of loneliness in an aged population. Archives of Gerontology and Geriatrics 41(3):223–233.
Shankar A, Demakakos P, Steptoe A, et al. (2013). Social
isolation, loneliness, and all-cause mortality in older
men and women. Proceedings of the National Academyof Sciences of the USA 110(15): 5797–5801.

Takehara H, Yanase T (2009). Evaluation of factors
aﬀecting the volume of the physical activities of thedaily living in elderly women : The diﬀerence from the
middle-aged. Journal of Home Economics of Japan
60(11): 937–944. (in Japanese and English abstract)
World Health Organization (2018). Global Health Observatory Data Repository: Healthy Life Expectancy(HALE) Data by Country 2016.
You KS, Lee H (2006). The physical, mental, and emotional health of older people who are living alone orwith relatives. Archives of Psychiatric Nursing 20(4):
193–201.