Factors related to a sense of economic insecurity among older adults who participate in social activities

Yuriko Inoue; Hisae Nakatani; Ichie Ono; Xuxin Peng

doi:10.1371/journal.pone.0301280

. 2024 Mar 28;19(3):e0301280. doi: 10.1371/journal.pone.0301280

Factors related to a sense of economic insecurity among older adults who participate in social activities

Yuriko Inoue ^1,^*, Hisae Nakatani ¹, Ichie Ono ², Xuxin Peng ¹

Editor: Sameh Eltaybani³

PMCID: PMC10977778 PMID: 38547217

Abstract

Japan has the highest life expectancy worldwide. Older adults who experience economic insecurity may refrain from seeking medical consultation or using long-term care insurance, and these behaviors may increase the incidence and progression of frailty. This study conducted a cross-sectional survey to identify factors related to a sense of economic insecurity among older adults who participate in social activities, and identified support measures. In total, 1,351 older adults aged ≥65 years who had participated in social activities voluntarily completed an anonymous self-administered questionnaire. The questionnaire encompassed their physical, cognitive, social, and psychological conditions, and economic insecurity. We performed univariate analysis considering a sense of economic insecurity as the dependent variable, and conducted multiple logistic regression analysis (forced entry method) considering the independent variables with p<0.1 as the covariates. Among the 872 filled questionnaires, 717 were analyzed as they had no missing data with respect to the responses to survey questions (valid response rate was 53.1%). Analysis results showed that 43.6% of the older adults had a sense of economic insecurity, which was most common among those aged 75–84 years, accounting for 47.3%, followed by those aged 65–74 years accounting for 44.1%, and those aged ≥85 years accounting for 31.5% (p<0.05). The sense of economic insecurity was not associated with physical conditions, subjective symptoms of dementia, or social conditions; however, it grew with increased loneliness (OR: 1.71, 1.002–2.92, p = 0.049) and decreased with an increased subjective sense of well-being (OR: 0.86, 0.81–0.92, <0.001). Economic insecurity among older adults was not associated with physical, cognitive, or social aspects, as reported in previous studies. The survey respondents constituted older adults who participate in social activities. Maintaining interactions within the community, even in old age, may prevent loneliness and improve subjective health.

Introduction

Japan has the highest life expectancy worldwide, reaching 81.5 years for men and 87.6 years for women after 2020 [1]. The population of older adults aged ≥85 years continues to increase, and Japan is about to enter the era of the 100-year life ahead of the rest of the world. However, the healthy life expectancy, a period with no restrictions in daily life, and average life expectancy differ by 10.2 years [2]. Living a healthy old age life without needing nursing care, even in longevity, has become an issue. Frailty is a state of increased vulnerability to changes in health status resulting from an age-related decline in physiological function [3]. Notably, the concept of frailty has been expanded beyond its physical aspects to include psychological and social aspects [4]. As the number of frail older adults increases with aging [5], preventive activities to maintain physical and mental function are important. Feng et al. reported that the risk factors associated with incident or increased frailty include low income among older adults [6]. According to a report by the Ministry of Health, Labour and Welfare, older adults account for a high percentage of the suicide mortality rate in Japan [7], and individuals aged ≥60 years account for 37.7% of the total number of suicide cases. In 2022, the most common causes and motives of suicide among older adults in Japan were “health problems,” followed by “family problems” and “economic and lifestyle problems” [8]. In conclusion, these trends suggest that there may be an association between a sense of economic insecurity among older adults and their physical and mental health. De Leo reported that suicide prevention for older adults should focus on the number of socio-environmental conditions that can be particularly worrisome in old age, such as decreased physical health, social isolation and loneliness, and economic insecurity [9]. Haines et al. reported that feelings of financial dissatisfaction adversely affect an individual’s subjective health [10]. According to a survey by the Cabinet Office of Japan [11], 59.0% of individuals aged 60–69 years and 35.8% of individuals aged ≥70 years were worried and insecure about their future economic prospects; therefore, older adults with economic insecurity may refrain from using medical care and long-term care insurance. This may lead to the incidence and progression of frailty.

In Japan, the Ministry of Health, Labour and Welfare (MHLW) encourages older adults to engage in social interactions with their neighbors and participate in social activities to prevent them from needing nursing care and becoming frail [12,13]. Examples of such activities include exercise and hobby activities in venues planned by health professionals in which older adults, regardless of their health status, can voluntarily participate. Participation in social activities costs nothing to approximately 200 yen (0 to approximately 1 US dollar) per month, and may decrease the incidence of functional disability [14] and cognitive decline [15]. A previous study analyzing differences in the prevalence of and factors associated with frailty in five Japanese residential areas reported that the higher level of social activities is attributable to the lower prevalence of frailty, and in most areas, a subjective economic status were significantly associated with frailty [16]. Encouraging participation in social activities, especially high-frequency social participation, could decrease the risk of and reverse the progression of frailty among middle-aged and older populations [17]. For low-cost social activities to function as a place for preventing frailty and suicide, it is necessary to investigate the actual state of the participants’ economic insecurity and discuss how to provide support for effective social activities. However, few historical studies specifically focus on older adults participating in social activities. Therefore, this study conducted a cross-sectional survey to identify factors related to a sense of economic insecurity among older adults who participate in social activities (not limited to older adults experiencing frailty) and to discuss support measures.

Materials and methods

Research design

An anonymous self-administered questionnaire was used in this cross-sectional study.

Research participants

The participants of the study were older adults aged 65 years or older who voluntarily participated in low-cost community-based social activities, such as exercise and hobby activities, and who were able to fill out a self-administered survey form. Based on statistical power calculations (power: 0.80, alpha value: 0.05), the sample size was 602 [18,19]. The collection rate was assumed to be around 45% in referring to previous studies [20]. We asked four community general support centers in Hiroshima City, Japan that had agreed to cooperate in this study to distribute the survey instrument. The questionnaire was distributed to 1351 older adults who participated in social activities during the survey period.

Survey methods

For the survey, the staff of the community general support centers explained in writing and orally the significance, purpose, methods, and ethical considerations of this study. These aspects are stated in the survey request letter, and the questionnaire was distributed among older adults who participate in social activities by hand. Individual older adults who received the questionnaires voluntarily completed it and then returned it either by posting in a sealed envelope or bringing it back to the collection box set up at the facilities where social activities were held. The survey was conducted from July to December 2022.

Survey contents

1) Basic attributes

Basic attributes constituted gender, age, household composition, marital status, spouse status, and whether the participant had a child (children). Respondents who selected “married” in response to marital status were also asked to state their spouse status (cohabiting, bereaved, divorced, or separated) in a multiple answer question. For the financial characteristic, we considered asking participants about their current income/savings and expenditures; however, we anticipated low response rates some older adults may be reluctant to answer questions relating to their personal information or may find it difficult to answer these questions. We also felt that using a large number of scales may be physically and mentally taxing for older adults. Therefore, we asked the participants about their subjective sense of anxiety about their economic situation. To determine their sense of economic insecurity, we asked the participants, “Do you have economic anxieties?” and asked them to respond using a four-point Likert scale (not worried, not too worried, a little worried, worried).

2) Physical conditions and subjective symptoms of dementia

Regarding the physical conditions and subjective symptoms of dementia, we inquired about the presence of illness, whether long-term care insurance services were used, and subjective symptoms of dementia. Subjective symptoms of dementia were assessed using a self-administered dementia checklist [21–23]. This checklist was developed to enable community-dwelling older adults to identify the decline in their cognitive and daily living functioning by filling out a self-administered form. The ten question items, including five items for subjective cognitive decline observed in the early stages of dementia and five items for subjective daily living functioning, were answered based on a four-point Likert scale for cognitive and daily living functioning, and significant correlations with the Mini-Mental State Examination (MMSE) [24] and Clinical Dementia Rating (CDR) [25] were confirmed. The score ranges from 10–40, with higher scores indicating greater severity of subjective dementia symptoms.

3) Social conditions

Regarding social conditions, we asked about the frequency of outings, participation in social activities, working status, and the presence or absence of social isolation. The frequency of outdoor activities and participation in social activities was based on a six-point Likert scale (daily, 5–6 times a week, 3–4 times a week, 1–2 times a week, 1–3 times a month, and less than once a month). Social isolation was assessed using the Lubben Social Network Scale (LSNS-6) [26]. The LSNS-6 is used to determine the number of people in a network using a six-point Likert scale (none, one, two, three or four, five through eight, nine or more) to determine emotional and instrumental support from family and relatives (three items) and friends, including those in the neighborhood (three items). The score ranges from 0–30; the more people there are in the network, the higher the score. A score below 12 points indicates social isolation.

4) Psychological conditions

Regarding psychological conditions, we assessed loneliness and subjective well-being. Loneliness was assessed using the University of California, Los Angeles Loneliness Scale, version 3. The UCLA Loneliness Scale (Loneliness) measures loneliness from the situational position with 20 items [27] or three items (short version) [28]. In this study, a shortened three-item version was used to improve the conciseness of the participants’ responses. The score ranges from 3–9; the higher the score, the lonelier the participant is, and a score of ≥6 indicates loneliness. Subjective wellbeing was assessed using the Philadelphia Geriatric Center Morale Scale (11-item) [29,30] developed for older adults. Eleven items (short version) were used in this study, and the questions were answered using a three-point Likert scale (yes, no, do not know). A positive “yes” response to subjective well-being is assigned a score of 1, and “no” or “do not know” a score of 0. The scores range from 0 to 11, with higher scores indicating a higher sense of well-being.

Analysis methods

The validity of the results is questionable if each scale used has missing values of 5% or more [31]. Therefore, the survey questionnaires without missing data on basic attributes, subjective symptoms of dementia, LSNS-6, loneliness, and subjective well-being were analyzed. Given that life expectancy is increasing around the world, with the number of older adults aged 85 and over accordingly growing, analyses of the social participation of older adults must take into account differences in age [32]. Therefore, age was categorized into three groups: 65–74, 75–84, and ≥85 years, based on the ≥65 age groups defined by the Long-Term Care Insurance Law, to which formal services for older adults in Japan are applicable. The frequency of outings and participation in social activities were categorized into two groups: at least once a week more and less than once a week, which are indicators of confinement [33]and criteria for lack of human contact [34]. Subjective symptoms of dementia were divided into “no” for scores below 18 and “yes” for scores of ≥18, based on previous studies [22]. The sense of economic insecurity was categorized into two groups: “not worried” and “not too worried” were classified as “not worried” and “a little worried” and “worried” were classified as “worried.” With regard to statistical analysis, we compared the differences between the two groups with respect to economic insecurity and basic attributes, physical, cognitive, and social conditions using the χ² test, and subjective well-being differences using the Mann-Whitney U-test. For multiple comparisons among the three age groups and basic attributes (physical, cognitive, and social), we used z-tests (the Bonferroni method for adjusting p-values), and subjective well-being differences using the Kruskal-Wallis test. To elucidate the factors related to economic insecurity for the “worried” group, we performed a univariate analysis considering the sense of economic insecurity as the dependent variable, and a performed multiple logistic regression analysis (forced entry method) with the independent variables as the covariates. The significance level of the covariates to be input into the model was set to less than 0.1. In the analysis, we set dummy variables, where 0 was assigned for “not worried” and 1 for “worried” with respect to sense of economic insecurity. For gender, we set 0 for male and 1 for female. For age, we set 0 for the 65–74 age group, 1 for the 75–84 group, and 2 for ≥85 age group. For household composition, we set 0 for “with spouse/children/others” and 1 for “living alone.” For marital status, we set 0 for “married” and 1 for “unmarried.” For spouse status, we set 0 for “no” and 1 for “yes” for each item of bereaved, divorced, and separated. For working status, we set 0 for “yes” and 1 for “no.” For subjective symptoms of dementia, we set 0 for “no” and 1 for “yes.” For social isolation, we set 0 for “no” and 1 for “yes.” For loneliness, we set 0 for “not lonely” and 1 for “lonely.” For subjective well-being, we used the total score of 0–11. Data were analyzed using the statistical software SPSS Version 27. A two-tailed p-value of <0.05 was considered to indicate statistical significance.

Ethical considerations

In terms of ethical considerations, the research participants received written and oral communication that participation was voluntary, that there would be no disadvantage from declining to participate, and that there would be no description of information that might lead to the identification of personal information. The request letter clearly stated that turning in the filled questionnaire would be regarded as consent, and that the questionnaire could not be withdrawn after it had been posted or dropped into the collection box. Participants were requested to indicate their agreement to participate by ticking a box, and their consent was obtained in writing. This study was approved by the Ethics Committee for Epidemiological Research of Hiroshima University (approval number: E2022-0020; approval date: June 9, 2022).

Results

Of the 872 filled questionnaires (response rate: 64.5%), 155 were excluded owing to missing data, and 717 were analyzed (valid response rate: 53.1%) (Fig 1, S1 Table).

The scales used in the study were tested for normality (Shapiro-Wilk test) and did not follow a normal distribution (P<0.01). The reliability coefficients (Cronbach’s alpha coefficients) for each scale were as follows: self-administered dementia checklist: 0.822; LSNS-6: 0.863; loneliness: 0.810; and subjective well-being: 0.758.

Characteristics based on age group

Table 1 shows the participant characteristics according to age group. Of these, 17.4% were male and 82.6% were female. The mean age was 78.7±6.0 years (65–96 years). In terms of age group, 25.9% were 65–74 years old, 56.3% were 75–84 years old, and 17.7% were ≥85 years old. Compared to the two age groups: 65–74 and 75–84 age groups, there were more males in the ≥85 age group (27.6%; p<0.05). In terms of household composition, 66.9% lived with their family and 33.1% lived alone. Most older adults living alone were identified in the ≥85 age group (50.4%; p<0.05). In total, 97.6% were married and 42.3% of the older adults were bereaved of their spouses. With regard to the sense of economic insecurity, 43.6% felt insecure. The percentage of older adults with a sense of economic insecurity was highest in the 75–84 age group at 47.3%, followed by the 65–74 age group at 44.1% and ≥85 age group at 31.5%; differences were observed among age groups (p<0.05).

Table 1. Characteristics according to age group.

	All		65–74		75–84		85+		p-value	Effect size
	(n = 717)		(n = 186)		(n = 404)		(n = 127)		p-value	Effect size
Basic attributes
Gender
Male	125	(17.4)	27	(14.5)	63	(15.6)	35	(27.6) ^a ^b	0.004 ^†	0.124
Female	592	(82.6)	159	(85.5)	341	(84.4)	92	(72.4) ^a ^b	0.004 ^†	0.124
Household composition
With spouse/children/others	480	(66.9)	141	(75.8)	276	(68.3)	63	(49.6) ^a ^b	<0.001 ^†	0.184
Living alone	237	(33.1)	45	(24.2)	128	(31.7)	64	(50.4) ^a ^b	<0.001 ^†	0.184
Marital Status (n = 714)
Married	700	(98.0)	178	(95.7)	395	(98.5)	127	(100.0)
Unmarried	14	(2.0)	8	(4.3)	6	(1.5)	0	(0.0)
Spouse Status (n = 700)
Cohabiting
No	344	(49.1)	53	(29.8)	198	(50.1) ^a	93	(73.2) ^a ^b	<0.001 ^†	0.284
Yes	356	(50.9)	125	(70.2)	197	(49.9) ^a	34	(26.8) ^a ^b	<0.001 ^†	0.284
Bereaved
No	404	(57.7)	140	(78.7)	222	(56.2) ^a	42	(33.1) ^a ^b	<0.001 ^†	0.302
Yes	296	(42.3)	38	(21.3)	173	(43.8) ^a	85	(66.9) ^a ^b	<0.001 ^†	0.302
Divorced
No	667	(95.3)	165	(92.7)	379	(95.9)	123	(96.9)	0.154 ^†	0.073
Yes	33	(4.7)	13	(7.3)	16	(4.1)	4	(3.1)	0.154 ^†	0.073
Separated
No	685	(97.9)	176	(98.9)	385	(97.5)	124	(97.6)	0.550 ^†	0.041
Yes	15	(2.1)	2	(1.1)	10	(2.5)	3	(2.4)	0.550 ^†	0.041
Having a child (Children)
Yes	670	(93.4)	167	(89.8)	381	(94.3)	122	(96.1)	0.050 ^†	0.091
No	47	(6.6)	19	(10.2)	23	(5.7)	5	(3.9)	0.050 ^†	0.091
Sense of economic insecurity
Not worried	404	(56.3)	104	(55.9)	213	(52.7)	87	(68.5) ^b	0.007 ^†	0.117
Worried	313	(43.7)	82	(44.1)	191	(47.3)	40	(31.5) ^b	0.007 ^†	0.117
Physical Conditions
Illness
No	105	(14.6)	51	(27.4)	40	(9.9) ^a	14	(11.0) ^a	<0.001 ^†	0.214
Yes	612	(85.4)	135	(72.6)	364	(90.1) ^a	113	(89.0) ^a	<0.001 ^†	0.214
Subjective symptoms of dementia
No	649	(90.5)	182	(97.8)	371	(91.8) ^a	96	(75.6) ^a ^b	<0.001 ^†	0.252
Yes	68	(9.5)	4	(2.2)	33	(8.2) ^a	31	(24.4) ^a ^b	<0.001 ^†	0.252
Using long-term care insurance services
No	640	(89.3)	181	(97.3)	381	(94.3)	78	(61.4) ^a ^b	<0.001 ^†	0.419
Yes	77	(10.7)	5	(2.7)	23	(5.7)	49	(38.6) ^a ^b	<0.001 ^†	0.419
Social Conditions
Frequency of outing
Once a week+	640	(89.3)	172	(92.5)	369	(91.3)	99	(78.0) ^a ^b	<0.001 ^†	0.170
Less than once a week	77	(10.7)	14	(7.5)	35	(8.7)	28	(22.0) ^a ^b	<0.001 ^†	0.170
Frequency of participation in social activities
Once a week+	609	(84.9)	164	(88.2)	342	(84.7)	103	(81.1)	0.222 ^†	0.065
Less than once a week	108	(15.1)	22	(11.8)	62	(15.3)	24	(18.9)	0.222 ^†	0.065
Working Status (n = 710)
Yes	84	(11.8)	34	(18.3)	39	(9.8) ^a	11	(8.8)	0.006 ^†	0.119
No	626	(88.2)	152	(81.7)	360	(90.2) ^a	114	(91.2)	0.006 ^†	0.119
Social Isolation
No	484	(67.5)	121	(65.1)	280	(69.3)	83	(65.4)	0.503 ^†	0.044
Yes	233	(32.5)	65	(34.9)	124	(30.7)	44	(34.6)	0.503 ^†	0.044
Psychological Conditions
Loneliness
Not lonely	637	(88.8)	163	(87.6)	361	(89.4)	113	(89.0)	0.825 ^†	0.023
Lonely	80	(11.2)	23	(12.4)	43	(10.6)	14	(11.0)	0.825 ^†	0.023
Subjective Well-Being	6.3	(2.74)	6.6	(2.73)	6.3	(2.71)	5.92	(2.81)	0.090 ^‡	0.180

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†: χ² and z-tests were performed to compare column proportions. p-values have been Bonferroni corrected

a: vs 65–74 years old

b: vs 75–84 years old, p<0.05.

‡: The Philadelphia Geriatric Center Morale Scale, Kruskal-Wallis test.

Marital status and work were tested, excluding those who did not want to answer the question.

Data is presented as either n (%) or mean±standard deviation.

Regarding physical conditions and subjective symptoms of dementia, 85.4% of the older adults suffered from certain illness, and there were more older adults attending the hospital in the 75–84 age group which accounted for 90.1% and the ≥85 age group accounting for 89.0% than in the 65–74 age group at 72.6% (p<0.05). In addition, 9.5% of the older adults had subjective symptoms of dementia, and the percentage increased with age, with 2.2% in the 65–74 age group, 8.2% in the 75–84 age group and 24.4% in the ≥85 age group (p<0.05). Moreover, 10.7% of the older adults used long-term care insurance. Older adults going out less than once a week accounted for 7.5, 8.7, and 22.0% in the 65–74, 75–84, and ≥85 years groups (p<0.05). No differences in frequency of participation in social activities were observed among the age groups. In the 65–74 years group, 18.3% accounted for working older adults (p<0.05). No difference was observed in social isolation among age groups, as well as in the psychological conditions of loneliness and subjective well-being.

Factors related to sense of economic insecurity

Table 2 shows the associations of basic attributes, physical conditions, subjective symptoms of dementia, social conditions, and psychological conditions with a sense of economic insecurity. No significant differences were observed in sense of economic insecurity by gender, household composition, marital status, or having a child (children). Among the physical conditions and subjective symptoms of dementia, no difference was found between older adults with economic insecurity and older adults without economic insecurity in all of the items of illness, subjective symptoms of dementia, and the use of long-term care insurance. Among the social conditions, there was no difference between older adults feeling economically insecure and older adults not feeling economically insecure in terms of frequency of outings and participation in social activities, working status, and social isolation. Among psychological conditions, older adults experiencing economic insecurity had higher rates of loneliness (< .001) and lower subjective well-being (< .001).

Table 2. Factors associated with sense of economic insecurity.

	All		Sense of economic insecurity				p-value	Effect size
	All		Not worried		Worried
	(n = 717)		(n = 404)		(n = 313)
Basic attributes
Gender
Male	125	(17.4)	78	(19.3)	47	(15.0)	0.133^a	0.056
Female	592	(82.6)	326	(80.7)	266	(85.0)	0.133^a	0.056
Age
65–74	186	(25.9)	104	(25.7)	82	(26.2)	0.007^a	0.117
75–84	404	(56.3)	213	(52.7)	191	(61.0)
85+	127	(17.7)	87	(21.5)	40	(12.8)
Household composition
With spouse/children/others	480	(66.9)	275	(68.1)	205	(65.5)	0.467^a	0.027
Living alone	237	(33.1)	129	(31.9)	108	(34.5)	0.467^a	0.027
Marital Status (n = 714)
Married	700	(98.0)	397	(98.8)	303	(97.1)	0.117^a	0.059
Unmarried	14	(2.0)	5	(1.2)	9	(2.9)	0.117^a	0.059
Spouse Status (n = 700)
Cohabiting
No	344	(49.1)	187	(47.1)	157	(51.8)	0.217^a	0.047
Yes	356	(50.9)	210	(52.9)	146	(48.2)	0.217^a	0.047
Bereaved
No	404	(57.7)	232	(58.4)	172	(56.8)	0.657^a	0.017
Yes	296	(42.3)	165	(41.6)	131	(43.2)	0.657^a	0.017
Divorced
No	667	(95.3)	384	(96.7)	283	(93.4)	0.040^a	0.078
Yes	33	(4.7)	13	(3.3)	20	(6.6)	0.040^a	0.078
Separated
No	685	(97.9)	388	(97.7)	297	(98.0)	0.795^a	0.010
Yes	15	(2.1)	9	(2.3)	6	(2.0)	0.795^a	0.010
Having a child (Children)
Yes	670	(93.4)	378	(93.6)	292	(93.3)	0.883^a	0.005
No	47	(6.6)	26	(6.4)	21	(6.7)	0.883^a	0.005
Physical Conditions
Illness
No	105	(14.6)	65	(16.1)	40	(12.8)	0.214^a	0.046
Yes	612	(85.4)	339	(83.9)	273	(87.2)	0.214^a	0.046
Subjective symptoms of dementia
No	649	(90.5)	365	(90.3)	284	(90.7)	0.860^a	0.007
Yes	68	(9.5)	39	(9.7)	29	(9.3)	0.860^a	0.007
Using long-term care insurance services
No	640	(89.3)	358	(88.6)	282	(90.1)	0.525^a	0.024
Yes	77	(10.7)	46	(11.4)	31	(9.9)	0.525^a	0.024
Social Conditions
Frequency of outing
Once a week+	640	(89.3)	354	(87.6)	286	(91.4)	0.108^a	0.060
Less than once a week	77	(10.7)	50	(12.4)	27	(8.6)	0.108^a	0.060
Frequency of participation in social activities
Once a week+	609	(84.9)	349	(86.4)	260	(83.1)	0.218^a	0.046
Less than once a week	108	(15.1)	55	(13.6)	53	(16.9)	0.218^a	0.046
Working Status (n = 710)
Yes	84	(11.8)	55	(13.8)	29	(9.3)	0.068^a	0.069
No	626	(88.2)	344	(86.2)	282	(90.7)	0.068^a	0.069
Social Isolation
No	484	(67.5)	275	(68.1)	209	(66.8)	0.713^a	0.014
Yes	233	(32.5)	129	(31.9)	104	(33.2)	0.713^a	0.014
Psychological Conditions
Loneliness
Not lonely	637	(88.8)	375	(92.8)	262	(83.7)	<0.001^a	0.144
Lonely	80	(11.2)	29	(7.2)	51	(16.3)	<0.001^a	0.144
Subjective Well-Being	6.28	(2.74)	6.81	(2.51)	5.61	(2.87)	<0.001^b	0.210

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a: χ² test.

b: The Philadelphia Geriatric Center Morale Scale, Mann-Whitney U test.

Marital status and working status were tested, excluding those who did not want to answer the question.

Data is presented as either n (%) or mean±standard deviation.

Table 3 shows the results of the multiple logistic regression analysis. The five covariates in univariate analysis (p<0.1): age, marital status, working status, loneliness, and subjective well-being, were input into Model 1. The odds ratio of older adults with economic insecurity was 0.55 (95% confidence interval: 0.33–0.91, p = 0.019) for age 85 years and older compared to 65–74 years for age, and 0.87 (95% confidence interval: 0.82–0.92, P<0.001) for subjective well-being. In this model, the maximum VIF value was 1.127, which did not exceed 10, indicating no multicollinearity. In Model 2, when adjusted for gender, household status, marital status, and spouse status (bereaved or separated), which may affect income and savings in addition to Model 1, the odds ratios were 0.49 (95% confidence interval: 0.29–0.83, P = 0.008) for age 85 years and older compared to 65–74 years for age, 0.87 (95% confidence interval: 0.82–0.92, P<0.001) for subjective well-being. In this model, the maximum VIF value was 2.235, which did not exceed 10, indicating no multicollinearity. In addition to Model 2, the odds ratios for older adults with economic insecurity in Model 3, adjusted for subjective symptoms of dementia and social isolation to account for physical and cognitive fragility and social ties, were 0.53 (95% confidence interval: 0.31–0.91, P = 0.021) for age 85 years and older compared to 65–74 years for age, 1.71 (95% confidence interval: 1.002–2.92, P = 0.049) for loneliness and 0.86 (95% confidence interval: 0.81–0.92, P<0.001) for subjective well-being. In this model, the maximum VIF value was 2.240, which did not exceed 10, indicating no multicollinearity.

Table 3. Factors related to sense of economic insecurity.

	Category	Model 1			Model 2			Model 3
	Category	OR	(95% CI)	p-value	OR	(95% CI)	p-value	OR	(95% CI)	p-value
Age	65–74 (reference)
	75–84	1.15	(0.79–1.66)	0.473	1.08	(0.74–1.58)	0.682	1.11	(0.76–0.62)	0.603
	85+	0.55	(0.33–0.91)	0.019	0.49	(0.29–0.83)	0.008	0.53	(0.31–0.91)	0.021
Divorced	Yes (reference: No)	1.85	(0.88–3.90)	0.105	2.23	(0.99–5.04)	0.053	2.18	(0.96–4.92)	0.061
Working Status	No (reference: Yes)	1.29	(0.78–2.12)	0.319	1.29	(0.78–2.12)	0.323	1.31	(0.79–2.16)	0.298
Loneliness	lonely (reference: Not lonely)	1.62	(0.96–2.72)	0.072	1.62	(0.96–2.73)	0.073	1.71	(1.002–2.92)	0.049
Subjective Well-Being	0–11	0.87	(0.82–0.92)	<0.001	0.87	(0.82–0.92)	<0.001	0.86	(0.81–0.92)	<0.001

Open in a new tab

Multiple logistic regression analysis (Forced entry method).

Model 1: Independent variables that were significantly different in univariate analysis were used as covariates.

Significance level of covariates to be entered: <0.1.

Model 2: Control for gender, household composition, marital status, spouse status (bereaved or separated).

Model 3: Control for gender, household composition, marital status, spouse status (bereaved or separated), subjective symptoms of dementia, social isolation.

OR: Odds ratio, CI: Confidence intervals.

Discussion

In this study, we examined factors related to a sense of economic insecurity among older adults, and explored support measures.

The older the age group of the participants, the greater the physical and cognitive decline and the greater the need for formal assistance through long-term care insurance were shown in this study. Long-term care insurance data can be used to identify frail individuals at high risk of needing long-term care and provide preventive care and interventions [35]. In Japan, approximately 7–10% of older adults living in the community are frail [36,37]. According to a report on the implementation of the long-term care insurance system in Hiroshima Prefecture, in 2022, the percentage of people certified as having a low long-term care insurance level (support needs: levels 1 and 2, and care needs level 1) in Japan was 9.3% (10.1% in Hiroshima Prefecture), which was similar to the 10.7% rate in this study. Lynch et al. reported that compared to people without difficulties, those with economic difficulties exhibited a 4.6 times decline in subjective cognitive functioning, a 3.38 times decline in independent activities of daily living (cooking, shopping, money management, etc.), a 3.79 times decline in daily living activities (walking, eating, clothes changing, toilet use, etc.), and a 3.24 times higher depression in their 29-year longitudinal study [38]. Conversely, no association was identified between a sense of economic insecurity and subjective symptoms of dementia, and physical and social conditions, such as the presence or absence of illness, decline in cognitive functioning, and the use of long-term care insurance. Kuiper et al. reported that low social participation was associated with the development of dementia [39]. The frequency of participation in social activities did not differ by age group, with 83.1% of older adults who expressed economic insecurity participating in social activities at least once a week. This result may reflect the characteristics of participants who exercised and interacted with neighbors, as the study was limited to participants who participated in community-based social activities. Comparing the 155 persons excluded from the analysis with those in the analysis as shown in S2 Table, there were no differences in gender, household status, marital status, presence of children, presence of illness, and economic insecurity. However, the mean age of the older adults who were not included in the analysis was 80.9 (SD 6.47), higher than that of the analyzed participants (<0.001), whose the mean age was 78.7 (SD 6.03). Further, the percentage of older adults not included in the analysis with subjective dementia symptoms was 19.3%, higher than the 9.5% of the analyzed participants (<0.001). Additionally, the percentage of older adults not included in the analysis who used long-term care insurance services was 30.5%, higher than the 10.7% of analyzed participants (<0.001). The study population is considered to be a relatively physically and cognitively independent group capable of participating in social activities. The 155 excluded individuals were willing to participate, but were excluded from the analysis because they did not respond to certain items, such as missing 5% or more on each scale or items regarding participation in social activities. They may have found it difficult to answer owing to some influence on their physical, mental, or cognitive functions. This shows that people with dementia symptoms and older adults using long-term care insurance also participate in social activities at the community level. We believe that it is important for older adults to participate in social activities that provide them with opportunities to access a variety of information and to meet kindred spirits in order to prevent the progression of frailty. In future studies, it is necessary to obtain the cooperation of the community general support center staff to expand the number of participants so that all those who participate in social activities can be analyzed.

Nearly half (43.6%) of the older adults aged 65 and older who participate in community activities, expressed a sense of economic insecurity. One possible reason for this may be the prolonged COVID-19 pandemic. Tull et al. reported increased health anxiety, financial worry, and loneliness under a stay-at-home due to the COVID-19 pandemic [40]. The period from July to December 2022, when we conducted our study, was a period of increased infections due to the spread of BA.5, one of the more infectious Omicron strains. Many social activities were carried out after ensuring infection prevention measures. Participation in social activities was voluntary, and it is possible that some older adults refrained from participating. Meanwhile, there were no gender differences in economic insecurity, but 82.6% of participants were women. Since women are more vulnerable to the social and economic effects of the pandemic and an increase in suicides has been reported [41], we believe it is necessary to continuously assess the actual situation of economic insecurity and provide social support to alleviate the sense of insecurity.

The percentage of older adults with economic insecurity was highest among those aged 75–84 years and 0.53 times lower among those aged 85 and older than among those aged 65–74 years in Model 3. As background for the inclusion of economic issues among the anxieties of those in their 60s and 70s, Chatfield compared life satisfaction between the employed and unemployed, and reported that the reason underlying the low life satisfaction among retired people is the sharp drop in income rather than job loss [42]. The sharp decline in income, longer period between retirement and death, and longer period of time required for nursing care were inferred to have led to a sense of economic insecurity. Therefore, social support may be especially important for retired for older adults between the ages of 65 and 75 years.

In particular, considering that their level of loneliness was 1.71 times higher, the need for interactions with acquaintances and neighbors became particularly important for older adults living alone, as well as for those living with family members. Similar to the results of the present study, in a survey of adults, Rohde et al. reported that economic insecurity affects mental health [43]. Kahn and Pearlin stated that even after excluding the impact of economic situation in old age, long-term economic problems affect physical functioning and depressive symptoms [44]. Cacioppo et al. stated that, in light of the possible role played by loneliness in depressive symptoms, greater attention to loneliness may be important to maximize the likelihood of the maintenance of health and functionality across the life span [45]. A study examining the contribution of various factors to health outcomes found socioeconomic factors to be 47%, health behaviors 34%, and clinical care 16%, indicating the importance of socioeconomic factors [46]. In this study, psychological conditions were associated with a sense of economic insecurity among older adults, highlighting the importance of preventing of early frailty progression through social activities. Gobbens proposed the integral conceptual model of frailty where physical, psychological, and social frailties lead to adverse health outcomes while mutually influencing one another [47]. Poor social participation due to social frailty has negative physical and mental consequences, which in turn lead to a negative cycle of further difficulties in social participation [48]. Maintaining interactions within the community, even in old age, may prevent loneliness and improve subjective health. Therefore, it is important to provide older adults with places where they can gather, participate in social activities at a low cost, and be supported by the staff at the community general support center.

Implication

Regarding the implications of this study, our results may lead health care providers who promote community-based social participation to consider support tailored to older adults’ age and psychological and economic insecurities. Furthermore, given that nearly half of the older adults participating in social activities felt economic insecurity, receiving support to alleviate this issue through social activities could contribute to improving their quality of life, including their mental health.

Research limitations

This study had several limitations. First, as this was a partial sampling survey conducted during social activities in an urban area of the city with a population of 1.1 million people in Japan, regional bias was not considered. Therefore, the study needs to be expanded in the future and conducted in rural areas. Second, this study measured the subjective economic insecurity of older adults, and the association between actual income and expenses could not be surveyed. Given the cross-sectional nature of the study design, further investigation through longitudinal and intervention studies involving factors based on objective indicators is needed to validate this association. Third, this survey does not reveal the actual situation of older adults in need of care who may have difficulty responding to such a self-administered questionnaire survey. Furthermore, the generalizability of the findings is limited since the study mainly focused on a group of older adults who were independent enough to complete the survey and participate in social activities. The background factors related to older adults’ insecurity regarding these issues should be studied further.

Conclusion

The study showed that 43.6% of older adults who participate in social activities had economic insecurity, and that economic insecurity differed by age group. In particular, the sense of economic insecurity was lower among older adults aged 85 and older, and higher among those who felt psychologically lonely and had a lower subjective sense of well-being. In the future, background factors related to loneliness and subjective well-being should be analyzed, including the number of interactions and the level of intimacy involved in social support.

Supporting information

S1 Table. Data for analysis.

(XLSX)

pone.0301280.s001.xlsx^{(76.9KB, xlsx)}

S2 Table. Comparison between analyzed and excluded participants.

(PDF)

pone.0301280.s002.pdf^{(115.9KB, pdf)}

Acknowledgments

The authors would like to thank all staff members of the community general support center who cooperated in this study. The authors would like to thank everyone who participated in the survey. The authors would like to thank Editage (www.editage.com) for English language editing. In writing this paper, the authors would like to thank Dr. Hirofumi Wakaki and Dr. Shinpei Imori of Hiroshima University for lending their expertise on statistical data analysis.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

IY FBK220531026 France Bed Medical Home Care Research Subsidy Public Incorporated Foundation https://www.fbm-zaidan.or.jp/subsidy/index.html The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. IY JPMJFS2129 Hiroshima University Research Fellowship https://fellowship.hiroshima-u.ac.jp/research/ The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0301280.r001

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PONE-D-23-12908Factors related to a sense of economic insecurity among older adults who participate in social activitiesPLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Authors,

Thank you for your submission

The following may help improve the quality of your report.

1. The Abstract:

Delete the following sentence: This may be because the ....

Line 49: prevents → may prevent

2. INTRODUCTION: Frailty is a state of increased ... Although the Abstract did not mention any thinf about fraility, the first paragraph of the Introduction maily focuses on fraility. So, it is confusing whether the current manuscript targets only frail older adults. You may consider revising the Abstract OR revising the Introduction so that readrs will not get confused.

3. Line 78: The top three causes and motives of suicide → Please describe the three causes and motives in detail.

4. Participants: who participated in social activities → this is a bit unclear. Please explain what social activities are you refering to and why you considered this group of older people to participate in the study. This should be also explained in the Introduction section so that readers would better understand the context of the data collection and the importance of the current studsy to this specific group of older adults.

5. The survey was conducted from July to December 2022. → This means that the survey was conducted during the COVID-19 pandemic, where several social activities and group gathering were prohibitied in may centers in Japan. This might have affected the available population, the response rate, and the results. Please elaborate on these issues in the Discussion.

6. Line 122: Please delete this title (you already have a title for eeach category)

7. Please elaborate on the psychometric properties of all used instruments. For example, did you examine its reliability of the outcome variable? If no, you need to explain why and how the results can be trusted in the absence of psychometeric properties. Also, you need to elaborate on the available tools to assess economic insecurities in the literature.

8. Line 151: UCLA: Mention the full name

9. Excludimng 155 participants from the analysis may introduce bias. Did you consider attrition analysis? Did you consider missing data analysis (such as, MCAR test)? Why did you condier missing data replacement?

10. Please consider draeing a flow chart that show the number of participants at each stage 8recruitment, dropout, etc.)

11. What about sample size calculation?

12. Table 2: It is unclear why you stratified the sample by age group. Please explain in the Method section.

13. Table 2: Please compute the effect size (p-value is not enough)

14. Table 3: Please compute the effect size (p-value is not enough)

15. Data reported in Table 1 ius already reported again in Tables 2 and 3 (pleasee delete any duplication and consider combining tables together).

16. Only 10% of the participants use LTC insurance. Does this mean that the overall condition of the study participants is relatively good, which may affect their response? I am curious to what extentthe current sample reporesnt the community-dwelling older adults in Hiroshima (or in japan). This might hinder the generalizability of the current results.

17. Table 3: the column "Category" is unclear. For example, in "Divorce," are ypou reporting data for "yes" or "no"?

18. Table 3: Did you examine multicollinearity?

19. In the Discussion section, please do not re-write the resuylts again (see for example Line 304).

20. Add a sub-section for the Implication.

===Good Luck===

Reviewer #2: The study investigates the factors associated with the sense of economic insecurity in a select group of older people consisting predominantly of females who participate in government sponsored social activities. The main findings were that the sense of economic insecurity was associated with the age cohort 75-84 years compared with > 84 or 66-74years, increasing loneliness and with subjective sense of well being (inverse association).

Although the overall study design and analysis are appropriate, the authors may wish to address the following:

1) The generalisability of the findings of this study is limited as the sample was derived form a select group that attends social activities. And I believe that this should be adequately emphasised as one of the major limitations.

2) To my understanding , although the authors have explained the rationale for selecting covariates in model 1, they have not done so with respect to models 2 and 3, and some of these variables have collinearity, for example loneliness, social isolation and marital status – perhaps authors may want to comment on this.

3) Some sections under results seem redundant , for example the authors have provided a fairly detailed account of the baseline sample characteristics in tables (table2) and text. I’m not sure such details on sample characteristics are necessary as they are not relevant to the objectives of this study.

4) In the introductory section, the authors state “ For low-cost social activities to function as a place for preventing frailty and suicide, it is necessary to investigate the actual state of the participants’ economic insecurity and discuss how to provide support for effective social activities”(lines 86-88) – are there any references or data to back up this statement.

5) The authors state that the findings of this study are somewhat different from previous studies in that no association was found between physical, cognitive or social aspects and economic insecurity. However, I don’t think that the authors have discussed the likely reasons for these observed differences.

6) I believe that the authors have to be circumspect with respect to some of assertions they have made in the discussion. For example, the authors state ( lines 329-334 “ in this study psychological conditions were associated with a sense of economic insecurity among older adults , highlighting the importance of preventing early frailty progression through social activities. Although the study findings support the 1st part of this statement, viz, in this study psychological conditions were associated with a sense of economic insecurity among older adults, their comments about preventing frailty cannot be inferred from the findings. Similarly, their basis for stating “ to prevent loneliness and improve subjective well being, establishing places where older adults-----------------social activities at low cost will improve their quality of life is not supported by the findings of this study.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2024 Mar 28;19(3):e0301280. doi: 10.1371/journal.pone.0301280.r002

Author response to Decision Letter 0

14 Dec 2023

Dear. Reviewer #1

Thank you for giving us the opportunity to strengthen our manuscript with your valuable comments and queries.

1. The Abstract:

Delete the following sentence: This may be because the ....

Line 49: prevents → may prevent

Reply:

Thank you for your comment. We agree with you and have incorporated these suggestions (p. 2, lines 47–49).

2. INTRODUCTION: Frailty is a state of increased ... Although the Abstract did not mention any thing about frailty, the first paragraph of the Introduction mainly focuses on frailty. So, it is confusing whether the current manuscript targets only frail older adults. You may consider revising the Abstract OR revising the Introduction so that readers will not get confused.

Reply:

Thank you for your comment. We agree with you and have accordingly revised our paper.

Specifically, we have recast our expression in the Abstract (p. 2, lines 27–29) and Introduction (p. 3–4, lines 59–60,75–79,90–93) to clarify that the paper does not focus only on frail older adults.

3. Line 78: The top three causes and motives of suicide → Please describe the three causes and motives in detail.

Reply:

Thank you for this suggestion. In response, we have detailed the three causes and motives of suicide. The most common cause and motive of suicide among older adults is "health problems," followed by "family problems," and "economic and lifestyle problems (p. 3, lines 65–69).　

4. Participants: who participated in social activities → this is a bit unclear. Please explain what social activities are you referring to and why you considered this group of older people to participate in the study. This should be also explained in the Introduction section so that readers would better understand the context of the data collection and the importance of the current study to this specific group of older adults.

Reply:

Thank you for your comment. The participants were older adults who participated in social activities that contributed to the prevention of long-term care, such as community-based exercise and hobby activities. The Ministry of Health, Labor and Welfare is working to expand these activities. We have added to and revised the Introduction (p. 4, lines 75–79) and Research Participants (p. 5, lines 100–103) sections to provide a better understanding of our research subjects and the importance of our research.

5. The survey was conducted from July to December 2022. → This means that the survey was conducted during the COVID-19 pandemic, where several social activities and group gathering were prohibited in may centers in Japan. This might have affected the available population, the response rate, and the results. Please elaborate on these issues in the Discussion.

Reply:

Thank you for your feedback. We agree with your assessment. The period from July to December 2022, when we conducted our study, was a period of increased infections due to the spread of BA.5, which was one of the more infectious Omicron strains. Accordingly, many social activities were carried out after ensuring infection prevention measures. In response to your excellent suggestion, we have explained our consideration of the effects of COVID-19 (p. 27–28, lines 344–356).　

6. Line 122: Please delete this title (you already have a title for each category)

Reply:

　Thank you for your suggestion. We accordingly removed this title.

7. Please elaborate on the psychometric properties of all used instruments. For example, did you examine its reliability 　　　　　　　

of the outcome variable? If no, you need to explain why and how the results can be trusted in the absence of psychometric properties. Also, you need to elaborate on the available tools to assess economic insecurities in the literature.

Reply:

　　　Thank you for this query. We have ensured that this information is provided in the Materials and Methods section. We also describe the instruments we used below:

① The self-administered dementia checklist:

The self-administered dementia checklist was developed as a 10-item and 2-factor instrument. Its factorial validity and internal reliability were confirmed. Cronbach’s α for the overall 10-item scale was 0.908. The concurrent and discriminant validities of the checklist were confirmed.

② The Lubben Social Network Scale (LSNS-6):

The Lubben Social Network Scale (LSNS-6) is used worldwide as a screening tool for social isolation in older adults. The reliability and validity of the Japanese version of the LSNS-6 were confirmed. Cronbach’s α was 0.82, the correlation coefficient for the test-retest was 0.92 (P＜0.001), and the intraclass coefficient for interrater reliability was 0.96 (95% confidence interval [CI] 0.90-0.99).

③ The University of California, Los Angeles Loneliness Scale, version 3 (UCLA-LS3):

The University of California, Los Angeles Loneliness Scale, version 3 (UCLA-LS3), is a revised version of the original version of the UCLA-LS by Russell. This revised scale has been adapted and validated in various subjects across different countries. A 3-item version (SF-3), based on the 20-item multidimensional revised UCLA-LS, was developed by Hughes. The three items on the SF-3 were selected because they showed the highest loading on the first factor of a three-factor model. The alpha coefficient for reliability was 0.72.

④ The Philadelphia Geriatric Center (PGC) Morale Scale

A model containing 11 of the original the Philadelphia Geriatric Center (PGC) Morale Scale items adequately fit both the American and Japanese data.

Based on your feedback, we examined the reliability of the outcome variable and added the finding to the Results (p. 10, lines 225–228).

Regarding the financial aspect, we considered whether we would ask participants about their current income/savings and expenditures. However, we anticipated low response rates, reasoning that some older adults may be reluctant to answer questions relating to their personal information or may find it difficult to answer such questions. We also considered that using a large number of scales would be physically and mentally taxing for older adults. Therefore, in this study, we asked participants about their subjective sense of anxiety about their economic situation. Specifically, to determine their sense of economic insecurity, we asked them to respond to the question, “Do you have economic anxieties?” using a four-point Likert scale (not worried, not too worried, a little worried, worried) (p. 6, lines 123–132).

8. Line 151: UCLA: Mention the full name

Reply:

Thank you for your comment. We added the full name for UCLA (The University of California, Los Angeles) (p. 7, lines 160–161).

9. Excluding 155 participants from the analysis may introduce bias. Did you consider attrition analysis? Did you consider missing data analysis (such as, MCAR test)? Why did you consider missing data replacement?

Reply:

Thank you for these insights. We compared and analyzed the 155 participants who were excluded from the analysis with those who were included in the analysis (Supporting information, Table. Comparison between Analyzed and Excluded Participants). These results were added to the Discussion (p. 27, lines 330–343) and Research limitations (p. 29–30, lines 400–404) sections.

Because the data in this study were not normally distributed, missing data analyses such as MCAR were not performed.

Among all participants included in the study, social activity participation was unknown for 64 participants and missing answers for basic attributes (e.g., gender, age) and illness were observed for 46 participants; these data were excluded from the analysis. In addition, 45 participants with a deficit of 5% or more in each scale were excluded from the study because of bias introduced by assigning mean values, etc. (Reference 30). (p. 8 lines 173–176).

10. Please consider drawing a flow chart that show the number of participants at each stage recruitment, dropout, etc.)

Reply:

　　　Thank you for this suggestion. We accordingly developed a flowchart of the participants in the study (Figure 1).

11. What about sample size calculation?

Reply:

Thank you for this question. The sample size for this study was analyzed using G*Power. Based on statistical power calculations, the sample size was 602. We added this information to the Analysis Methods section and cited relevant articles (p. 5, lines 102–106).

12. Table 2: It is unclear why you stratified the sample by age group. Please explain in the Method section.

Reply:

Thank you for this query. Life expectancy is increasing globally, and the number of older adults aged 85 and over is accordingly growing. In response to your excellent suggestion, we added our rationale for stratifying our sample by age group to the Analysis Methods section; this decision was based on prior research (Reference 31) (p. 8, lines 176–181).

13. Table 2: Please compute the effect size (p-value is not enough)

Reply:

Thank you for this suggestion. We computed the effect sizes and included them in Table 2 (p. 12–16, lines 254–259).

14. Table 3: Please compute the effect size (p-value is not enough)

Reply:

Thank you for this guidance. As above, we computed the effect sizes and included them in Table 3 (p. 18–22, lines 273–277).

15. Data reported in Table 1 is already reported again in Tables 2 and 3 (please delete any duplication and consider combining tables together).

Reply:

Thank you for pointing this out. We combined the tables and removed the table that was originally Table 1.

16. Only 10% of the participants use LTC insurance. Does this mean that the overall condition of the study participants 　　　　　

is relatively good, which may affect their response? I am curious to what extent the current sample represent the community-dwelling older adults in Hiroshima (or in Japan). This might hinder the generalizability of the current results.

Reply:

Thank you for this question. The older adults in the study were relatively physically and cognitively independent and able to complete the self-administered questionnaire survey and participate in social activities. According to a report on the implementation of the long-term care insurance system in Hiroshima Prefecture, in 2022, the percentage of people certified as having a low long-term care insurance level (support needs: levels 1 and 2, and care needs level 1) in Japan was 9.3% (10.1% in Hiroshima Prefecture), which was similar to the 10.7% rate in this study. We added this information to the Discussion (p. 26, lines 308–316) and included more References to substantiate these claims (Reference 34–36).

17. Table 3: the column "Category" is unclear. For example, in "Divorce," are you reporting data for "yes" or "no"?

Reply:

Thank you for checking in about this. We have revised Table 3 to clarify this point (we are reporting data for yes/no responses). Additionally, we modified our results to more closely report the results of the logistic analysis by age group (p. 23–25, lines 280–304).

18. Table 3: Did you examine multicollinearity?

Reply:

Thank you for this query. We added a discussion of multicollinearity to the Results (p. 23, lines 283–284;

p. 23, 288–289 and 295–296).

19. In the Discussion section, please do not re-write the results again (see for example Line 304).

Reply:

Thank you for this insight. We agree and have incorporated this suggestion in our revised manuscript.

20. Add a sub-section for the Implication.

Reply:

Thank you very much for this guidance. We accordingly added an Implication subsection (p. 29, lines 388–392). The implication of this study is that health professionals who promote community-based social participation can provide support tailored to older adults' specific ages and levels of psychological and economic insecurity. This can improve older adults’ quality of life, including their mental health, and prevent frailty.

Dear. Reviewer #2

Thank you for giving us the opportunity to strengthen our manuscript with your valuable comments and queries.

The study investigates the factors associated with the sense of economic insecurity in a select group of older people consisting predominantly of females who participate in government sponsored social activities. The main findings were that the sense of economic insecurity was associated with the age cohort 75-84 years compared with > 84 or 66-74years, increasing loneliness and with subjective sense of well-being (inverse association).

Although the overall study design and analysis are appropriate, the authors may wish to address the following:

1) The generalizability of the findings of this study is limited as the sample was derived form a select group that attends social activities. And I believe that this should be adequately emphasized as one of the major limitations.

Reply:

Thank you very much for your excellent suggestion. We agree. As you pointed out, the study population was rather specific; it comprised older adults who were relatively physically and cognitively independent and who were able to complete a self-administered questionnaire survey and participate in social activities. In response, we highlighted the limited generalizability of the findings in the Discussion (p. 26, lines 308–316; p. 27, lines 330–343) and Limitations (p. 29–30, lines 400–404).

2) To my understanding, although the authors have explained the rationale for selecting covariates in model 1, they have not done so with respect to models 2 and 3, and some of these variables have collinearity, for example loneliness, social isolation and marital status – perhaps authors may want to comment on this.

Reply:

Thank you for your suggestion. We added our rationale for the selection of the covariates in Models 2 and 3 and detailed the multicollinearity in the Results (p. 23, lines 284–296).

3) Some sections under results seem redundant, for example the authors have provided a fairly detailed account of the baseline sample characteristics in tables (table2) and text. I’m not sure such details on sample characteristics are necessary as they are not relevant to the objectives of this study.

Reply:

Thank you for these insights. Life expectancy is increasing globally, and the number of older adults aged 85 and over is accordingly growing. In response to your excellent suggestion, we added our rationale for stratifying our sample by age group to the Analysis Methods section; this decision was based on prior research (Reference 31) (p. 8, lines 176–181). To remove the redundancies in the results section, we have combined the tables and removed what was originally Table 1.

4) In the introductory section, the authors state “For low-cost social activities to function as a place for preventing frailty and suicide, it is necessary to investigate the actual state of the participants’ economic insecurity and discuss how to provide support for effective social activities” (lines 86–88) are there any references or data to back up this statement.

Reply:

Thank you for checking in about this. Prior research reported that community-level social participation and support prevent suicide (Reference 15). De Leo reported that suicide prevention for old adults should focus on the number of socio-environmental conditions that can be particularly worrisome in old age, such as decreased physical health, social isolation and loneliness, and economic insecurity (Reference 16). We added new text and references to the Introduction to substantiate these claims (p. 4, lines 82–86).

Reply:

Thank you very much for this observation. In response, we included some possible reasons for these differences in the Discussion section (Reference 38) (p. 26–27, lines 324–343).

6) I believe that the authors have to be circumspect with respect to some of assertions they have made in the discussion. For example, the authors state (lines 329–334 “in this study psychological conditions were associated with a sense of economic insecurity among older adults, highlighting the importance of preventing early frailty progression through social activities. Although the study findings support the 1st part of this statement, viz, in this study psychological conditions were associated with a sense of economic insecurity among older adults, their comments about preventing frailty cannot be inferred from the findings. Similarly, their basis for stating “to prevent loneliness and improve subjective well-being, establishing places where older adults-----------------social activities at low cost will improve their quality of life is not supported by the findings of this study.

Reply:

Thank you for this feedback. In this study showed that psychological status was associated with economic insecurity among older adults. As your comment, we cannot infer from the results of this study regarding the prevention of frailty. We agree with your assessment and have made according changes to the Discussion (p. 29, lines 384–387) and the Abstract (p. 2, lines 47–49). Notably, we added a reference (Reference 45-47) in our revisions based on your comment to the Discussion. We also highlighted that a key implication of this study is that social participation can prevent frailty (p. 29, lines 388–392).

Attachment

Submitted filename: renamed_1b3be.docx

pone.0301280.s003.docx^{(63.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0301280.r003

Decision Letter 1

Sameh Eltaybani

16 Jan 2024

PONE-D-23-12908R1Factors related to a sense of economic insecurity among older adults who participate in social activitiesPLOS ONE

Dear Dr. Yuriko,

Please submit your revised manuscript by Mar 01 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Sameh Eltaybani, Ph.D

The University of Tokyo

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Thank you for the thorough revision. The current version of the manuscript looks far better than the previous one. Yet, the Reviewer still pointed out some issues that need to be considered before considering the current manuscript for publication.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: (No Response)

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: (No Response)

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: 1) The references 15 and 16 in the introduction, the authors have now cited in their response, refer to the association between environmental factors /activities and suicide or suicide prevention, and are not relevant frailty. Therefore, they are not the appropriate references for suggesting any potential association between the sense of economic insecurity or social activities and frailty.

2) The authors now mention the sample size but fail to discuss estimated power or set alpha values.

3) The authors may wish to consider sensitivity analyses including the 155 participants excluded from analysis, as there are significant differences in their baseline characteristics - they are significantly older, more likely to have dementia symptoms and use long-term care insurance.

4) Under implications, the authors state “ Regarding the implication of this study, it reveals that health professionals who promote community- based social participation can provide support tailored to older adults’ age and level of psychological and economic insecurity . This work can improve older adults’ quality of life , including their mental health, and prevent frailty”. I’m not sure one could draw these conclusions as they are not underpinned by the findings of this study – the study did not investigate the potential consequences or implications of the sense of economic security, or the possible interventions to ameliorate the sense of economic security. Similarly, the concluding section too was outside the scope of the findings of this study. For example, I don’t believe that the findings of this study support the following conclusion – “Notably , this study showed that preventive measures to limit loneliness and increase subjective well-being through the use of social activities play an important role in reducing economic insecurity”.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

PLoS One. 2024 Mar 28;19(3):e0301280. doi: 10.1371/journal.pone.0301280.r004

Author response to Decision Letter 1

2 Feb 2024

Dear. Reviewer #2

Thank you for giving us the opportunity to strengthen our manuscript with your valuable comments and queries.

1) The references 15 and 16 in the introduction, the authors have now cited in their response, refer to the association between environmental factors /activities and suicide or suicide prevention, and are not relevant frailty. Therefore, they are not the appropriate references for suggesting any potential association between the sense of economic insecurity or social activities and frailty.

Reply:

Thank you for pointing this out. In response to your suggestion, we removed Reference 15 because it was an article that referred to the association between environmental factors/activities and suicide or suicide prevention. Reference 16 has been moved to the section related to suicide in the Introduction (accordingly, Reference 16 is Reference 9 in the revised manuscript) (p. 3, lines 69–72). Additionally, we have added references that demonstrate any potential association between the sense of economic insecurity or social activities and frailty (References 16 and 17) (p. 4, lines 86–91).

2) The authors now mention the sample size but fail to discuss estimated power or set alpha values.

Reply:

Thank you for this suggestion. We set a power of 0.80 and an alpha value of 0.05. We have added this information to the Research participants subsection of the Methods section (p. 5, line 108).

Reply:

Thank you for your feedback. The 155 excluded individuals were willing to participate, but were excluded from the analysis because they did not respond to certain items, such as missing 5% or more on each scale or items regarding participation in social activities. They may have found it difficult to answer owing to some influence on their physical, mental, or cognitive functions. This shows that people with dementia symptoms and older adults using long-term care insurance also participate in social activities at the community level. We believe that it is important for older adults to participate in social activities that provide them with opportunities to access a variety of information and to meet kindred spirits in order to prevent the progression of frailty. In future studies, it is necessary to obtain the cooperation of the community general support center staff to expand the number of participants so that all those who participate in social activities can be analyzed. We have added the underlined section to the Discussion (p. 27, lines 345–355).

4) Under implications, the authors state “ Regarding the implication of this study, it reveals that health professionals who promote community- based social participation can provide support tailored to older adults’ age and level of psychological and economic insecurity . This work can improve older adults’ quality of life , including their mental health, and prevent frailty”. I’m not sure one could draw these conclusions as they are not underpinned by the findings of this study – the study did not investigate the potential consequences or implications of the sense of economic security, or the possible interventions to ameliorate the sense of economic security. Similarly, the concluding section too was outside the scope of the findings of this study. For example, I don’t believe that the findings of this study support the following conclusion – “Notably, this study showed that preventive measures to limit loneliness and increase subjective well-being through the use of social activities play an important role in reducing economic insecurity”.

Reply:

Thank you for these insights. We agree. As you pointed out, the design of this study is cross-sectional, and further longitudinal and intervention studies are needed in the future to verify the associations. In response, we have revised and deleted the parts of the Implication (p. 29, lines 402–404), Limitations (p. 30, lines 412–414), and Conclusions (“Notably, this study showed that preventive measures to limit loneliness and increase subjective well-being through the use of social activities play an important role in reducing economic insecurity”.) that were pointed out by you.

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Submitted filename: renamed_bf6c6.docx

pone.0301280.s004.docx^{(16.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0301280.r005

Decision Letter 2

Sameh Eltaybani

14 Feb 2024

PONE-D-23-12908R2Factors related to a sense of economic insecurity among older adults who participate in social activitiesPLOS ONE

Dear Dr. Yuriko,

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Sameh Eltaybani, Ph.D

The University of Tokyo

Academic Editor

PLOS ONE

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Additional Editor Comments:

Thank you for the thorough revision. The quality of the current version is by far much better than the previous version. Yet, some minor issues need to be addressed.

1) The sample size calculation is unclear. The mentioned description is insufficient. You need to describe in detail how the sample size was computed including the name of the software used.

2) In the STATISTICAL ANALYSIS section, p-value is on-tailed or two tailed?

3) Table 1: you used symbols a,b and A,B,C. This is confusing. Do not use capital and small forms of the same letter to denote different things. Please use different symbols. Also, reporting the results of the post-hoc analysis (A,B,C) is unclear. You may need to consult a statistician about how to report the results of the post-hoc analysis clearly. For example, what is the meaning of BC and ABC?

4) You need to elaborate on the IMPLICATIONS of the current study (Line 401).

5) Figure 1: The quality is extremely low. Please provide a hig-quality figure.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: (No Response)

Reviewer #2: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: (No Response)

Reviewer #2: Yes

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Reviewer #2: (No Response)

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PLoS One. 2024 Mar 28;19(3):e0301280. doi: 10.1371/journal.pone.0301280.r006

Author response to Decision Letter 2

25 Feb 2024

Responses to Reviewers’ Comments

Manuscript Number：PONE-D-23-12908R2

Full Title：Factors related to a sense of economic insecurity among older adults who participate in social activities

Dear. Editor

Thank you for giving us the opportunity to revise and strengthen our manuscript based on your valuable comments and queries.

1) The sample size calculation is unclear. The mentioned description is insufficient. You need to describe in detail how the sample size was computed including the name of the software used.

Reply:

Thank you for your comment. We used G*Power to calculate our sample size. The Cabinet Office 2020 White Paper on Older Adults reports that 74.1%, or three-quarters of those aged 60 and older, are living without economic insecurity, more than that in the 2016 survey (see Annual Report on the Ageing Society [Summary] FY2020: https://www8.cao.go.jp/kourei/english/annualreport/2020/pdf/2020.pdf). However, we expected the percentage of older adults with economic insecurity to increase to approximately 30% with the COVID-19 pandemic. We predicted that those with good physical, social, and psychological status would be 0.8 times more likely to have economic insecurity than those with low economic insecurity, which we set at 602 on a one-tailed test. We also examined the sample size based on the Events per variable following Peduzzi et al., who reported that data should be collected so that the Events per variable is greater than 10 (Peduzzi et.al., 1996). We examined the following explanatory variables to identify the factors associated with economic insecurity: basic attributes: 1) gender, 2) age, 3) household composition, 4) marital status, spouse status (5) bereaved, 6) divorced, 7) separated), 8) whether the participant had a child (children); physical conditions:9) presence of illness, 10) subjective symptoms of dementia, 11) whether long-term care insurance services were used; social conditions:12) frequency of outings, 13) frequency of participation in social activities, 14) working status, 15) the presence or absence of social isolation; and psychological conditions: 16) loneliness, and 17) subjective well-being. Assuming 30% of the respondents have a sense of economic insecurity, the sample size must be at least 567.

2) In the STATISTICAL ANALYSIS section, p-value is on-tailed or two tailed?

Reply:

Thank you for your concern. We performed a two-tailed test. We have added the following sentence to the manuscript to reflect this: “A two-tailed p-value of <0.05 was considered to indicate statistical significance.” (p. 9, lines 212-213).

Reply:

Thank you for this suggestion. We have revised the symbols “a” to “†” and “b” to “‡”. We have also corrected the reporting of the post-hoc analysis results to “†: χ² and z-tests were performed to compare column proportions. p-values have been Bonferroni corrected. a: vs 65-74 years old, b: vs 75-84 years old, p<0.05” (p. 12-16, lines 259-262).

References:

1) Mielgo-Ayuso J, Aparicio-Ugarriza R, Castillo A, Ruiz E, Ávila JM, Aranceta-Batrina J, et al. Physical activity patterns of the Spanish population are mostly determined by sex and age: Findings in the ANIBES study. PLoS One. 2016;11(2):e0149969. doi: 10.1371/journal.pone.0149969.

2) Koyama A, Hashimoto M, Tanaka H, Fujise N, Matsushita M, Miyagawa Y, et al. Malnutrition in Alzheimer’s disease, dementia with Lewy bodies, and frontotemporal lobar degeneration: Comparison using serum albumin, total protein, and hemoglobin level. PLoS One. 2016;11(6):e0157053. doi: 10.1371/journal.pone.0157053.

4) You need to elaborate on the IMPLICATIONS of the current study (Line 401).

Reply:

Thank you very much for this suggestion. The implications were suggested by Reviewer #1, and in the second draft, the following text was added: “Regarding the implication of this study, it reveals that health professionals who promote community-based social participation can provide support tailored to older adults' age and levels of psychological and This work can improve older adults' quality of life, including their mental health, and prevent frailty.” In the third draft, we revised parts of the text in accordance with the suggestions we received from reviewer #2 as follows: “Regarding the implications of this study, our results may lead health care providers who promote community-based social participation to consider support tailored to older adults’ age and psychological and economic insecurities.” We agree with your suggestion to elaborate on the implications, so we have further revised the paper in Draft 4 as follows: “Regarding the implications of this study, our results may lead healthcare providers who promote community-based social participation to consider support tailored to older adults’ age and psychological and economic insecurities. Furthermore, given that nearly half of the older adults participating in social activities felt economic insecurity, receiving support to alleviate this issue through social activities could contribute to improving their quality of life, including their mental health.” (p. 29, lines 401–407).

5) Figure 1: The quality is extremely low. Please provide a hig-quality figure.

Reply:

Following on your suggestion, we have re-created Figure 1 to ensure that it is of high-quality.

Attachment

Submitted filename: Responses to Reviewers.docx

pone.0301280.s005.docx^{(26KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0301280.r007

Decision Letter 3

Sameh Eltaybani

14 Mar 2024

Factors related to a sense of economic insecurity among older adults who participate in social activities

PONE-D-23-12908R3

Dear Dr. Yuriko,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Sameh Eltaybani, Ph.D

The University of Tokyo

Academic Editor, PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0301280.r008

Acceptance letter

Sameh Eltaybani

19 Mar 2024

PONE-D-23-12908R3

PLOS ONE

Dear Dr. Inoue,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Table. Data for analysis.

(XLSX)

pone.0301280.s001.xlsx^{(76.9KB, xlsx)}

S2 Table. Comparison between analyzed and excluded participants.

(PDF)

pone.0301280.s002.pdf^{(115.9KB, pdf)}

Attachment

Submitted filename: renamed_1b3be.docx

pone.0301280.s003.docx^{(63.1KB, docx)}

Attachment

Submitted filename: renamed_bf6c6.docx

pone.0301280.s004.docx^{(16.5KB, docx)}

Attachment

Submitted filename: Responses to Reviewers.docx

pone.0301280.s005.docx^{(26KB, docx)}

Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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PERMALINK

Factors related to a sense of economic insecurity among older adults who participate in social activities

Yuriko Inoue

Hisae Nakatani

Ichie Ono

Xuxin Peng

Roles

Abstract

Introduction

Materials and methods

Research design

Research participants

Survey methods

Survey contents

1) Basic attributes

2) Physical conditions and subjective symptoms of dementia

3) Social conditions

4) Psychological conditions

Analysis methods

Ethical considerations

Results

Fig 1. Flowchart of the study participants.

Characteristics based on age group

Table 1. Characteristics according to age group.

Factors related to sense of economic insecurity

Table 2. Factors associated with sense of economic insecurity.

Table 3. Factors related to sense of economic insecurity.

Discussion

Implication

Research limitations

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Sameh Eltaybani

Roles

Author response to Decision Letter 0

Decision Letter 1

Sameh Eltaybani

Roles

Author response to Decision Letter 1

Decision Letter 2

Sameh Eltaybani

Roles

Author response to Decision Letter 2

Decision Letter 3

Sameh Eltaybani

Roles

Acceptance letter

Sameh Eltaybani

Roles

Associated Data

Supplementary Materials

Data Availability Statement

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