SSM - Population Health 19 (2022) 101229

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The association between elder abuse and refrainment from daily activities
during the COVID-19 pandemic among older adults in Japan: A
cross-sectional study from the Japan Gerontological Evaluation Study
Chie Koga a, *, Taishi Tsuji b, Masamichi Hanazato a, Koryu Sato c, Katsunori Kondo a, daCenter for Preventive Medical Sciences, Chiba University, 1-33 Yayoi-cho, Inage-ku, Chiba-shi, Chiba, 263-8522, Japan
Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba City, Japan
Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Yoshida-Konoecho, Sakyo-ku, Kyoto-shi, Kyoto, 6068315, JapandCenter for Gerontology and Social Science, National Center for Geriatrics and Gerontology, 7-430 Morikoka-cho, Obu-shi, Aichi, 474-8511, Japanbc

A R T I C L E I N F O

A B S T R A C T

Keywords:
Elder abuse
COVID-19
Behavioral refrain
Violence

Objectives: Elder abuse is a public health issue that is thought to have increased during the COVID-19 pandemic
due to lockdowns and behavioral restrictions. This study examines the association between elder abuse andrefrainment from daily activities during the pandemic.
Methods: We used data from a self-administered mail survey conducted by the Japan Gerontological Evaluation
Study (JAGES) from November 2020 to February 2021 in 11 municipalities. Our participants included 18,263
older adults (age ≥65 years) who were independent in their daily lives. Logistic regression analysis was con­ducted to evaluate the association between elder abuse and refrainment from 10 daily activities, and the total
number of refrained behaviors.
Results: Experiences of abuse were reported by 288 participants (1.6%). The risk of elder abuse was 1.37 times(95% confidence interval, 1.04–1.81) higher among those who refrained from shopping for food and daily ne­
cessities and 1.60 times (1.20–2.13) higher among those who refrained from interaction with neighbors, thanthose who did not. Also, a dose-response relationship was observed where the risk of abuse increased with thenumber of restrictions.
Conclusion: The risk of elder abuse increased as the number of refrained behaviors increased which suggests thatrefrainment from multiple behaviors may significantly increase the risk of elder abuse, compared with refrain­
ment from a single behavior. To avoid increasing the risk of abuse in likely future pandemics, it is necessary tomaintain social connections without face-to-face contact, or with adequate infection control measures.

1. Introduction
The outbreak of the coronavirus pandemic (COVID-19) has restricted
the activities of many people, including older adults (Lim et al., 2020).
In March 2020, it was estimated that more than 3.4 billion people in 84
countries were restricted from going out (Bouziri et al., 2020). Although
the Japanese Government did not implement lockdowns of cities orother legally-mandated measures, a stay-at-home order was compliedwith by the general population. In April 2020, major cities experienced
60%–80% reductions in the numbers of people going out. Home
confinement raised concerns about the physical health of older adults,
such as muscle weakness due to reduced physical activity, and about theeffects on their psychological and social health, due to limited in­teractions with others (Maugeri et al., 2020; United Nations, 2020, pp.
1–16; Woods et al., 2020). There were also concerns about increasing
violence, such as elder abuse in the home, due to lockdowns and re­strictions on going out (Chang & Levy, 2021; Han & Mosqueda, 2020;
Makaroun, Bachrach, & Rosland, 2020; United Nations, 2020, pp. 1–16).
Elder abuse is a public health challenge and is defined as “a single, or
repeated act, or lack of appropriate action, occurring within any rela­tionship where there is an expectation of trust, which causes harm or
distress to an older person” by the World Health Organization (WHO,2014). It reduces the well-being of older adults and negatively affects
their health by increasing the risks of, for example, depression and* Corresponding author. Center for Preventive Medical Sciences, Chiba University, 260-8670, Japan.
E-mail address: chiekoga@chiba-u.jp (C. Koga).
https://doi.org/10.1016/j.ssmph.2022.101229
Received 20 May 2022; Received in revised form 25 August 2022; Accepted 10 September 2022
Available online 13 September 2022
2352-8273/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

C. Koga et al.

SSM - Population Health 19 (2022) 101229(physical, psychological, and financial) using a self-reported question­
naire developed in collaboration between researchers, doctors, social
epidemiologists, and social workers (Koga, Hanazato, et al., 2020; Koga,
Tsuji, et al., 2020). Because a definition of abuse has not been estab­lished, it is challenging to clarify criteria for determining what behavior
constitutes elder abuse. To ascertain whether or not abuse had occurred,
our study asked questions that referred to specific acts or feelings, suchas being beaten, having one’s self-esteem damaged, or having one’ssavings or pension taken. Participants were asked, “Please answer about
your life during the period of the declaration of a state of emergency due
to the outbreak of COVID-19 (April to May 2020). Please check all theboxes that apply to your daily activities.” For physical abuse, partici­
pants were asked, “Did you experience physical violence from yourfamily, such as being hit, kicked, having objects thrown at you, or being
shut in a room?” Psychological abuse was measured by the following
question, “Did you experience an act by your family that harmed yourself-esteem, such as verbal abuse, cutting remarks, or being ignored forlong periods?” Financial abuse was measured by the question, “Do anyof your family members take or use your savings or pension benefits
without your consent?” Those who checked one or more of these ques­
tions were considered to have experienced abuse; other participants
were deemed to not have experienced abuse.

suicide (Koga, Tsuji, Hanazato, Takasugi, & Kondo, 2022; Koga, Tsuji,Hanazato, Suzuki, & Kondo, 2020; Luo & Waite, 2011; Wong & Waite,2017). Low level of social support and social capital can be risk factors
for elder abuse (Johannesen & Logiudice, 2013; Koga, Hanazato, Tsuji,
Suzuki, & Kondo, 2020; Park, 2018). Chang and colleagues studied 897
older adults in the United States and showed that elder abuse waspositively associated with financial strain but negatively associated witha sense of community and physical distancing during the COVID-19
pandemic (Chang & Levy, 2021). Filipska and colleagues studied 347
hospitalized patients in Poland and found that low income, chronic
diseases, poor relationships with family, and depression were associatedwith an increased risk of elder abuse during the pandemic (Filipska
et al., 2021). Du and Chen recruited 10,362 Chinese older adults andreported that those who frequently participated in social activities wereless likely to experience abuse during the pandemic (Du & Chen, 2021).
This evidence indicated that social interaction is important in reducing
the risk of elder abuse regardless of the COVID-19 pandemic. Although
the association between social support and elder abuse has not been
investigated enough, a study on 3157 older adults has reported that
positive social interaction was a possible modifying effect on interper­
sonal strain (Zheng, Li, Kong, & Dong, 2019). Similarly, another study
on 897 older adults argued that fewer interpersonal strains influenced
mistreatment via loneliness, but social support moderated the influence.
Moreover, the indirect effect of interpersonal strain on abuse via lone­
liness is more substantial for those with lower levels of support thanthose with higher levels of support (Chokkanathan, 2017). However,these studies during COVID-19 did not account for refrainment fromvarious daily activities. Risk factors of elder abuse have been concep­
tualized in four categories: older person, perpetrator, their relationship,
and the environment (Johannesen & Logiudice, 2013). Behavioral re­strictions during the pandemic could affect relationship between older
adults and caregivers and affect their surrounding environments. The
risk of abuse may differ depending on the types of behaviors that are
refrained from.
This study examines the association between elder abuse andrefrainment from various behaviors in daily life during the COVID-19
pandemic. We used a large, representative dataset of older Japanese
adults. We hypothesized that people who refrain from multiple behav­
iors are more likely to have an increased risk of elder abuse than those
who refrain from a single behavior. By examining the relationship be­
tween refrainment from daily activities and elder abuse, this study canhelp prevent an increase in abuse during a future pandemic.

2.3. Refrainment behaviors
The explanatory variables were the presence or absence of a decreasein 10 daily living behaviors and the total number of refrained behaviors(0, 1, 2, 3, or ≥4). Participants were asked, “Please answer about yourdaily life during the period of the declaration of a state of emergency(April to May 2020) due to the outbreak of COVID-19 infection. Pleasecheck all the boxes that apply to the activities that you reduced thefrequency of or ceased: 1. Eating out; 2. Shopping for groceries and daily
necessities; 3. Shopping for items other than groceries and daily neces­sities; 4. Exercising indoors, such as at a gym; 5. Exercising or walking
outdoors; 6. Interacting with neighbors; 7. Visiting medical institutions(except in cases of suspected COVID-19 infection); 8. Using public
transportation; 9. Visiting museums and movie theaters; and 10.
Participating in community events. Each choice was recorded as 1, forthose who decreased the frequency of the behavior or ceased it, or as 0,
for those who did not change their behavior. The total number ofrefrained behaviors was the sum of refrained behaviors, excluding var­iables negatively associated with elder abuse. Those who refrained fromfour or more behaviors were merged into one category. This research is
to determine the impact of COVID-19 on their lives and health of older
adults ages 65 years and older who are not eligible for long-term careinsurance. These options about activities in the daily lives of older adults
were developed by the collective effort of researchers from various
disciplines. Although the Japanese Government did not implement
lockdown of cities or other legally mandated measures, people followed
stay-at-home and refrained from their activity primarily by themselves.

2. Materials and methods
2.1. Selection and description of participants and the setting
We used the cross-sectional data of a self-administered mail survey
conducted by the Japan Gerontological Evaluation Study (JAGES) from
November 2020 to February 2021 in 11 municipalities. We included
questions on elder abuse to determine the frequency of elder abuse andits related factors during the COVID-19 pandemic. JAGES is a large,
epidemiological study group of older adults (aged ≥65 years)
throughout Japan who are without physical or cognitive disabilities(Kondo, Rosenberg, National Center for Geriatrics, & Gerontology,
2018). We randomly selected and sent questionnaires to 24,613 eligible
people. We received responses from 19,928 participants (response rate,
81.0%). We excluded 1655 participants whose sex and age could not be
confirmed or who were reported in error. Thus, the analytical popula­tion of this study was 18,263.

2.4. Covariates
In line with former studies that focused on elder abuse, we included
basic demographic information, including sex (male or female), agegroup (65–69, 70–74, 75–79, 80–84, and ≥85 years-old), educational
attainment (≤9 or ≥10 years), employment status (never employed, pastworker, or current worker), subjective socioeconomic status (poor,
average, or rich), marital status (married, widowed, divorced, unmar­
ried, or other), and living arrangements (alone, with family members, orother facilities), and change in income due to COVID-19 (decreased or
not decreased) (Dong, Chen, Fulmer, & Simon, 2014; Dong, Simon, &Evans, 2014; Koga, Hanazato, et al., 2020; Koga, Tsuji, et al., 2020).
Depressive symptoms were measured using the 15-item GeriatricDepression Scale, which defines mild and severe depression as 5–9
points and >10 points, respectively (Koga, Tsuji, et al., 2020). For

2.2. Elder abuse during the COVID-19 pandemic
The outcome variable was the presence or absence of elder abuse
during the period of Japan’s first declaration of a state of emergency(April to May 2020). Elder abuse was measured across three dimensions
2

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SSM - Population Health 19 (2022) 101229

measuring independence in activities of daily living, participants wereasked, “Do you regularly receive nursing care or assistance for walking,bathing, and/or using a toilet?” Answers were recorded using thefollowing 3-point scale: 1. No need for nursing care or assistance; 2.
Requiring but not receiving nursing care or assistance; and 3. Needing
and receiving nursing care or assistance.

4. Discussion/conclusion
This investigation revealed that the risk of elder abuse was higher
among those who refrained from shopping for food and daily necessities
and from interaction with neighbors. The risk of abuse increased as thenumber of refrained behaviors increased. Our results demonstrated thatrefrainment from multiple behaviors might be significantly associatedwith an increased risk of abuse over that of refrainment from a single
behavior. To the best of our knowledge, this is the first study to inves­tigate the association between elder abuse and refrainment from various
daily activities during the COVID-19 pandemic.
We found clear associations between abuse and refrainment fromshopping for food and daily necessities and from interaction withneighbors. These two activities can be considered the most routinely
performed among the explanatory variables. In Japan, there was no
substantial restriction on going out, such as a lockdown. However, thegovernment recommended that people avoid places that meet the 3 Cs
(closed space, crowded place, and close-contact setting) (Lim et al.,2020). People and communities that faithfully followed the instructions
might have had a higher risk of abuse. Restriction of activities, such as
shopping and social interaction, could be an indicator of increased riskof abuse. Previous studies have suggested that social support can be aprotective factor against elder abuse (Chokkanathan, 2017; Dong &Simon, 2008; Melchiorre et al., 2013). Therefore, proactive contact (e.g.,
from neighbors) with older adults who are no longer seen in neighbor­hoods (e.g., at the supermarket) may help prevent abuse.
This study also showed that the risk of elder abuse increased as thenumber of refrained behaviors increased. Previous studies have reported
that abuse occurs most commonly among family members living
together (Takasaki et al., 2005). When behaviors in daily life are
restricted and the time spent at home is increased, more opportunities
arise for conflicts among family members living together, contributing
to an increased risk of abuse. Although our findings did not reach sig­
nificance level for some of the refrained behaviors, their scores indicateda trend toward increasing risk. In other words, they suggested thatrefrainment from multiple behaviors in daily life could accumulate asubstantial risk.
Contrary to our hypothesis, we found that refrainment from eatingout was negatively associated with the risk of elder abuse. This finding is
consistent with a previous study, which suggested that maintaining
physical distance (staying six feet apart from other persons) was asso­
ciated with a lower risk of abuse during the pandemic (Chang & Levy,
2021). Out of our participants, 69.5% answered that they had reduced
the frequency of eating out, which was the most common behavioral
refrainment. It is possible that those who reduced eating out also fol­
lowed social norms and considered social benefits. Such people may
tend to have strong social ties, which can mitigate the risk of abuse(Webster et al., 2020).
Based on these results, policy recommendations would be as follows.
Increase the home visiting and watching over towards older adults who
decrease to go out. Moreover, actively promote the use of appropriate
services is important for families who are considered to have a heavy
burden of care.

2.5. Statistical analysis
Descriptive statistics were generated to summarize the characteris­tics of participants. To investigate the relationship between elder abuse
and refrainment from behaviors during the COVID-19 pandemic, we
conducted a logistic regression analysis and calculated the odds ratios(OR) and 95% confidence intervals (CI) for the risk of elder abuse, after
adjusting for all covariates. We created two models. First, the 10 types of
behavioral refrainment were simultaneously investigated in Model 1. In
Model 2, the total number of refrained behaviors was added to Model 1.
We calculated p for trend when the total number of refrained behaviors
was included as a continuous variable. Because some variables in theanalysis were missing, multiple imputations were performed. A total of
20 multiple imputed datasets were created, including all measured
variables, using a multivariate normal imputation method with a“missing at random” assumption. The estimated parameters were com­bined using Rubin’s combination methods (Rubin, 2004). All statisticalanalyses were conducted using Stata 16/IC (StataCorp, College Station,
TX, USA).
3. Results
3.1. Participants’ characteristics
Table 1 shows the characteristics of study participants. The numberof those who experienced abuse during the declared state of emergency
was 288 (1.6%). Those who reduced their activities were 12680 (69.5%)
for eating out, 3822 (21.0%) for shopping for groceries and daily ne­
cessities, 6694 (36.7%) for shopping for items other than groceries anddaily necessities, 3875 (21.2%) for exercising indoors, such as at a gym,
2741 (15.0%) for exercising or walking outdoors, 4246 (23.3%) forinteracting with neighbors, 3107 (17.0%) for visiting medical in­stitutions (except in cases of suspected COVID-19 infection), 7321
(40.1%) for using public transportation, 7426 (40.7%) for visiting mu­
seums and movie theaters, and 5690 (31.2%) for participation in com­munity events).
3.2. Results of logistic regression analysis
Table 2 shows the OR for the associations between elder abuse andbehavioral refrainment among older Japanese adults. In Model 1, therisks of abuse were 1.37 times (CI, 1.04–1.81) and 1.60 times (CI,
1.20–2.13) higher, respectively, for those who reduced grocery shop­
ping and interaction with neighbors. than for those who did not. In
contrast, those who reduced eating out had a 0.75 times (CI, 0.54–0.96)
lower risk of abuse than those who did not. Because the variable eatingout was negatively associated with abuse in Model 1, it was excluded
from Model 2, along with the total number of refrained behaviors. In
Model 2, the risk of abuse was 1.84 times (CI, 1.09–1.82) higher for two
reduced behaviors, 2.40 times (CI, 1.31–4.41) higher for three reduced
behaviors, and 2.86 times (CI, 1.25–6.54) higher for four or more
reduced behaviors, compared with those who had zero reduced behav­
iors (excluding the eating out variable). When the total number ofrefrained behaviors was treated as a continuous variable, its p for trend
was 0.003. For sensitivity analysis, we included the eating out variable inModel 2, and found a similar result (Supplementary Table).

4.1. Strengths and limitations
This study explored the associations between elder abuse andrefrainment from various behaviors in daily life during the COVID-19
epidemic. We found the risk of abuse to be differentiated by the typeof refrained behavior. We used a large, representative dataset that wascollected using rigorous random sampling methods; many earlier studies
related to the COVID-19 pandemic have relied on online surveys orconvenience sampling. However, several limitations of our study must
be mentioned. First, there is a possibility of reverse causality due to thecross-sectional design. Those who experienced abuse may have been
restricted in their daily lives by their abusers. Therefore, future3

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Table 1
Characteristics of study participants.
All%

Experienced abuse%

Elder abuse

18236

100.0%

288

1.6%

Number of refrained behaviors
None
One decreased
Two decreased
Three decreased
More than four

2625
2362
3023
2911
7315

14.4%
13.0%
16.6%
16.0%
40.1%

22
27
41
47
151

0.8%
1.1%
1.4%
1.6%
2.1%

Eating out
Not decreased
Decreased

5556
12680

30.5%
69.5%

93
195

1.7%
1.5%

Shopping for groceries and daily necessities
Not decreased
Decreased

14414
3822

79.0%
21.0%

195
93

1.4%
2.4%

Shopping for items other than groceries and daily necessities
Not decreased
11542
Decreased
6694

63.3%
36.7%

165
123

1.4%
1.8%

Exercising indoors, such as at a gym
Not decreased
Decreased

14361
3875

78.8%
21.2%

209
79

1.5%
2.0%

Exercising or walking outdoors
Not decreased
Decreased

15495
2741

85.0%
15.0%

216
72

1.4%
2.6%

Interacting with neighbors
Not decreased
Decreased

13990
4246

76.7%
23.3%

177
111

1.3%
2.6%

Visiting medical institutions (except in cases of suspected COVID-19 infection)
Not decreased
15129
Decreased
3107

83.0%
17.0%

216
72

1.4%
2.3%

Using public transportation
Not decreased
Decreased

10915
7321

59.9%
40.1%

155
133

1.4%
1.8%

Visiting museums and movie theaters
Not decreased
Decreased

10810
7426

59.3%
40.7%

153
135

1.4%
1.8%

Participating in community events
Not decreased
Decreased

12546
5690

68.8%
31.2%

172
116

1.4%
2.0%

Sex
Male
Female

8669
9567

47.5%
52.5%

106
182

1.2%
1.9%

Age group
65–59
70–74
75–79
80–84
85≤

3300
5483
4438
3113
1902

18.1%
30.1%
24.3%
17.1%
10.4%

54
74
67
59
34

1.6%
1.3%
1.5%
1.9%
1.8%

Education≤9 yrs≥10 yrs
Missing

4310
13469
457

23.6%
73.9%
2.5%

90
188
10

1.5%
1.2%
1.0%

Employment status
Never
Past worker
Current worker
Missing

2083
10239
5306
608

11.4%
56.1%
29.1%
3.3%

34
163
81
10

1.6%
1.6%
1.5%
1.6%

Subjective socioeconomic status
Poor
Usual
Rich
Missing

3982
10759
3228
267

21.8%
59.0%
17.7%
1.5%

141
114
29
4

3.5%
1.1%
0.9%
1.5%

Marital status
MarriedWidowedSeparated
Unmarried

12246
3589
1029
788

67.2%
19.7%
5.6%
4.3%

180
54
27
18

1.5%
1.5%
2.6%
2.3%
(continued on next page)4

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Table 1 (continued )All%

Experienced abuse

%

Other
Missing

123
461

0.7%
2.5%

5
4

4.1%
0.9%

Living arrangement
Living alone
Living with someone
Missing

3443
14618
175

18.9%
80.2%
1.0%

66
219
3

1.9%
1.5%
1.7%

Depression
NormalMild depressive
Severe depressive
Missing

12607
3626
1214
789

69.1%
19.9%
6.7%
4.3%

99
104
72
13

0.8%
2.9%
5.9%
1.6%

Change in income due to COVID-19
Decreased
Not decreased
Missing

2213
15100
923

12.1%
82.8%
5.1%

56
215
17

2.5%
1.4%
1.8%

Activity of Daily Living (ADL)
Unnecessary
Necessary and supported
Necessary and not supported
Missing

16263
942
543
488

89.2%
5.2%
3.0%
2.7%

212
38
25
13

1.3%
4.0%
4.6%
2.7%

Not experienced abuse, n = 17,948 (98.4%); Experienced abuse, n = 288 (1.6%).

Table 2
Odds ratios for the association between elder abuse and behavioral decline among older Japanese adults (n = 18,236).
Model 1
ORs

Model 2p

95% CI

ORsp

95% CI

1.00
1.12
1.84
2.40
2.86

0.666
0.022
0.005
0.013

0.68
1.09
1.31
1.25

1.84
3.10
4.41
6.54

Number of refrained behavior
None
One decrease
Two decrease
Three decrease
More than four
Eating out
Not decrease
Decreased

1.00
0.75

0.049

0.56

1.00

0.027

1.04

1.81

1.00
1.16

0.319

0.86

1.57

Shopping for items other than groceries and daily necessities
Not decrease
1.00
Decreased
0.91
0.520

0.69

1.20

1.00
0.74

0.047

0.55

1.00

Exercising indoors, such as at a gym
Not decrease
1.00
Decreased
1.15

0.383

0.84

1.57

1.00
1.05

0.744

0.77

1.44

Exercising or walking outdoors
Not decrease
1.00
Decreased
1.16

0.327

0.86

1.57

1.00
1.01

0.952

0.74

1.38

Interacting with neighbors
Not decrease
Decreased

0.001

1.20

2.13

1.00
1.35

0.052

1.00

1.82

Visiting medical institutions (except in cases of suspected COVID-19 infection)
Not decrease
1.00
Decreased
1.22
0.171
0.92

1.64

1.00
1.06

0.696

0.78

1.44

Using public transportation
Not decrease
Decreased

Shopping for groceries and daily necessities
Not decrease
1.00
Decreased
1.37

1.00
1.60

1.00
1.11

0.455

0.84

1.46

1.00
0.89

0.425

0.66

1.19

Visiting museums and movie theaters
Not decrease
1.00
Decreased
1.23

0.208

0.89

1.70

1.00
0.96

0.802

0.68

1.35

Participation in community events
Not decrease
1.00
Decreased
1.16

0.366

0.84

1.60

1.00
0.99

0.934

0.71

1.37

n = 18,236. Model 1 and Model 2 adjusted for age, sex, education attainment, employment status, subjective socioeconomic status, marital status, living arrangement,
depression, change in income, and activity of daily living.
5

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SSM - Population Health 19 (2022) 101229

Data availability

longitudinal studies should be conducted. Second, there is a possibilityof selection bias, due to nonrespondents. Participants who suffered fromsevere abuse may not have responded to the questionnaire. It should be
noted also that we studied only older adults who were physically andcognitively independent. Despite the fact that physical and cognitive
impairments are significant risk factors of abuse, we could not invite
such participants (Du & Chen, 2021; Filipska et al., 2021). Third, ourstudy recruited only Japanese participants. Therefore, generalizability
to other countries with different pandemic situations and cultures
should be verified. Thus, we cannot discuss any differences related to
cultural contexts. Fourth, reporting errors in the presence of abuse may
have occurred; our questionnaires were self-reported and have not beenvalidated. The observed prevalence of abuse (1.6%) may seem very low,
given that a previous meta-analysis estimated the global prevalence tobe 15.7% (Yon, Mikton, Gassoumis, & Wilber, 2017). Nonetheless, therate we observed was reasonable. In 2019 in Japan, 34,057 cases wereconsulted or reported to municipalities; 16,928 cases were confirmed aselder abuse by caregivers in an older population of approximately 36
million (Ministry of Health Labor and Welfares of Japan, 2019). Despite
the above limitations, this study has provided important perspectives
regarding the relationship between elder abuse and the reduction of
behaviors during the COVID-19 pandemic.

Data will be made available on request.
Acknowledgement
We are extremely grateful to all study participants for the use of theirpersonal data. We would like to express our deepest gratitude to
everyone who participated and cooperated in the surveys.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ssmph.2022.101229.
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5. Conclusions
The risk of elder abuse was higher among those who refrained fromshopping for food and daily necessities and from interaction withneighbors than among those who did not. The risk of abuse increased as
the number of refrained behaviors increased. This indicates thatrefrainment from multiple behaviors may significantly increase the riskof elder abuse above that of refrainment from a single behavior. Because
another pandemic is likely to occur in the future, it is necessary tomaintain social connections, without face-to-face contact or withadequate infection control measures, to avoid increasing the risk ofabuse.
Statement of ethics
This study was reviewed and approved by the ethics committees of
Chiba University (3442). The study was conducted in accordance withthe principles of the Declaration of Helsinki and its later amendments.
All participants provided written informed consent when they returned
a questionnaire.
Funding sources
This study used data from Longevity Science Research and Devel­
opment Project, Japan Agency for Medical Development (AMED)(JP19dk0110034, JP20dk0110034), Social welfare and epidemiologicalresearch for planning measures to cope with lifestyle issues caused bysocioeconomic disparity at the National Institute for Longevity Sciences(H30-Cardiovascular, etc.-General-004), JSPS (Japan Society for the
Promotion of Science) KAKENHI (grant Nos. 20K13721), a JST-OPERA
program grant (JPMJOP1831), and costs commissioned bymunicipalities.
Author contributions
C.K.: conceived the design, analyzed the data, and wrote the firstdraft of the article. C.K. and K.S.: performed the literature review. T.T.,
K.S., and K.K.: collected the data. K.K. is the principal.
Declaration of competing interest
The authors have no conflicts of interest to declare.
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Glossary
OR: odds ratio
CI: confidence interval

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