Gender differences of social interactions and their effects on subjective well-being among Japanese elders

Abstract

Objectives:
Gender differences of social interactions and their effects on subjective well-being among Japanese elders over three years were examined.

Methods:
Repeated measurements of 498 elders over a three-year survey interval were obtained from a baseline mail survey and two- and three-year follow-up surveys. Outcomes were analyzed using Hierarchical Linear Modeling.

Results:
Male elders were more likely to have a spouse and work at paid jobs, while female elders were likely to have more frequent contacts with their child/children and more interactions with friends. As the elders aged over three years, life satisfaction decreased, while depression did not show any significant overall trend. There were no beneficial effects of social interactions on change in well-being, although social participation, interaction with friends, and conversation with spouse were beneficially related to baseline levels of both depressive tendency and life satisfaction. Among female elders only, the number of children had beneficial effects on life satisfaction.

Conclusions:
There are modest gender differences of the impact of social interactions on the well-being of Japanese elders, and the number of children seems to be more important as potential sources of support for female rather than male elders. Spousal conversation and non-obligatory social interaction such as unpaid social activities and friendship seem to be important for both male and female elders in Japan. These findings suggest that social relations among Japanese elders may be moving away from more gender dependent patterns seen in the past.

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Gender differences of social interactions and their
effects on subjective well-being among Japanese
elders
Hideki Okabayashi a & Gavin W. Hougham b
a Department of Psychology, Meisei University, Hino-City, Tokyo, Japan
b Department of Medicine and Center for Health and the Social Sciences, The University of
Chicago, Chicago, United States
Version of record first published: 24 Apr 2013.
To cite this article: Hideki Okabayashi & Gavin W. Hougham (2013): Gender differences of social interactions and their
effects on subjective well-being among Japanese elders, Aging & Mental Health, DOI:10.1080/13607863.2013.788997
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Gender differences of social interactions and their effects on subjective
well-being among Japanese elders
Hideki Okabayashi
a
and Gavin W. Hougham
b
a
Department of Psychology, Meisei University, Hino-City, Tokyo, Japan;
b
Department of Medicine and Center
for Health and the Social Sciences, The University of Chicago, Chicago, United States
(Received 9 October 2012; final version received 10 March 2013)
Objectives: Gender differences of social interactions and their effects on subjective well-being among Japanese elders over
three years were examined.
Methods: Repeated measurements of 498 elders over a three-year survey interval were obtained from a baseline mail
survey and two- and three-year follow-up surveys. Outcomes were analyzed using Hierarchical Linear Modeling.
Results: Male elders were more likely to have a spouse and work at paid jobs, while female elders were likely to have more
frequent contacts with their child/children and more interactions with friends. As the elders aged over three years, life
satisfaction decreased, while depression did not show any significant overall trend. There were no beneficial effects of
social interactions on change in well-being, although social participation, interaction with friends, and conversation with
spouse were beneficially related to baseline levels of both depressive tendency and life satisfaction. Among female elders
only, the number of children had beneficial effects on life satisfaction.
Conclusions: There are modest gender differences of the impact of social interactions on the well-being of Japanese elders,
and the number of children seems to be more important as potential sources of support for female rather than male elders.
Spousal conversation and non-obligatory social interaction such as unpaid social activities and friendship seem to be
important for both male and female elders in Japan. These findings suggest that social relations among Japanese elders
may be moving away from more gender dependent patterns seen in the past.
Keywords: subjective well-being; growth curve modeling; temporal change; social interaction
Introduction
Twenty-five years after House, Landis, and Umberson
(1988) reviewed the major extant findings on the links
between social relationships and health, their concluding
words about the need to “further understand” these pro-
cesses still obtain. The purpose of this study is to examine
gender differences of several sources of social interactions
on subjective well-being over three years among Japanese
elders. In addition, we examine trajectories of subjective
well-being over three years.
Japan and other East Asian countries are often consid-
ered to be characterized by a collectivist orientation rather
than more individualist orientations said to be found
among Western countries (Kitayama, Markus, & Kuro-
kawa, 2000). East Asian countries have historically been
influenced by Confucianism, as evidenced by a prepon-
derance of traditional norms governing household divi-
sions of labor, high gender income gaps (the difference
between median earnings of men and women relative to
median earning of men is 33% in 2006; OECD, 2010),
low representation of women in national politics (12% of
parliamentarians are women in 2010; UNDP, 2010), and
other areas.
Such traditional norms typically stress filial piety and
paternal hierarchical family relations. Thus, in Japan,
women are more likely to take caregiving roles and to be
more tightly bound to their families than men. Although
these cultural tendencies have been weakening due to
recent influences of globalization, urbanization, and other
factors, these traditions are still strongly rooted in Japa-
nese society, especially among elders. Many commenta-
tors, therefore, believe that the effects of social and family
relations on well-being are greater in Japan than in West-
ern countries. For example, Koyano, Hashimoto, Fukawa,
Shibata, and Gunji (1994) found that family centrality
was important in the social support system of Japanese
elderly. That is, Japanese elders feel that family members
living together are the most dependable, followed by chil-
dren living apart, and that neighbors and friends are less
dependable. While there seem to be mostly supportive
relationships among family members living together,
there were also negative effects found in these types of
families, especially among multigenerational households
in one East Asian country in particular, Korea (Jeon, Jang,
Rhee, Kawachi, & Cho, 2007). However, recent contra-
dictory findings by Fiori, Antonucci, and Akiyama (2008)
*Corresponding author. Email: okabaya@psy.meisei-u.ac.jp
Ó2013 Taylor & Francis
Aging & Mental Health, 2013
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directly compared social relations using elderly samples
from the U.S. and Japan. They found that while elders in
functionally or structurally restricted social network types
in the U.S. had higher depressive symptomatology than
those in other types of networks — such as diverse,
friend-focused, or family-focused — surprisingly there
were no differences in depressive symptomatology by net-
work type in Japan. They suggested that “because in Japan
relationships may be viewed as predetermined or obliga-
tory, rather than constructed or voluntary, the Japanese
may learn to be happy with whatever network they have
(Fiori et al., 2008, p. 223).” However, if they examine
effects of each source of social interaction, not examining
the effect of network types, they would find beneficial
effects on well-being in Japan, as reported by other com-
mentators (Okabayashi, Liang, Krause, Akiyama, & Sugi-
sawa, 2004), and their explanations would not be
considered complete. There appears to be additional need
to explore the relationship between social relations and
subjective well-being in Japan.
In a more historically oriented way, Iwao (2008)
described typical gender-segregated lives in the Japanese
generation born before World War II. During early adult-
hood and midlife, “even though the constitution declared
that men and women were equal, male and female roles
gradually become established according to which it was
the men who worked and earned the salaries and the
women who stayed at home and devoted themselves to
the housework and childrearing (pp. 532).” In old age,
“this generation of Japanese men and women had lived in
completely separate worlds over many years, without
showing their real feelings to each other. The women had
built up close relationships with their children and female
friends, and one can even say that sometimes the children
took on the role of the absent father. The wider the gulf
between husband and wife become, the closer she grew to
the children (pp. 536).” Iwao’s narrative suggests that
while elderly women in Japan enjoy interacting with
friends and adult children but tend to avoid their “useless”
husbands (sometimes even called “large rubbish”), elderly
men become lonely after retirement because they do not
have strong emotional bonds to their wives and children
and wider social networks (such as friends) in their com-
munity. Is this really true? Do Japanese male elders really
experience such a sad life?
In a recent U.S. longitudinal study, Kendler, Meyers,
and Prescott (2005) found that “emotionally supportive
social relationships are substantially more protective
against major depression for women than for men,” but
there are few empirical longitudinal studies examining
gender differences in well-being among Japanese elders.
Therefore, the purpose of this study is to examine gender
differences of several sources of social interactions on
subjective well-being over three years among Japanese
elders. We believe that elderly women are more likely to
have a more diverse network, including children or
friends, than elderly men. We also believe that while male
elders are likely to be influenced by the relationships with
their spouses, female elders are likely to be influenced by
other relationships such as with children or friends, rather
than with their spouses.
In addition, we examine trajectories of subjective well-
being over three years. Over time, subjective well-being
among elders tends to decrease with functional health
(House, Lantz, & Herd, 2005). However, the rate of
decline may not be the same among all elders. That is, for
some elders subjective well-being may be relatively stable,
while for others it may dramatically decrease. We examine
whether social interactions were related to the change rates
of subjective well-being over a three year period among
Japanese elders, and we also examine whether there are
gender differences of these effects on well-being.
We will next review the relationship of each source of
social interaction with subjective well-being among eld-
ers. To capture social interaction from various sources
comprehensively, we measure three different aspects of
these interactions thought to be among the most important
(Cohen, Underwood, & Gottlieb, 2000; Lubben &
Gironda, 2003): family relationships, social participation,
and interactions with friends. For elders, family relation-
ships typically refer to those with spouses and adult chil-
dren. Social participation usually refers to participating in
paid work, or unpaid structured social activities in senior
centers or volunteer centers. Interactions with friends or
one’s spouse constitute informal relations and companion-
ship, which are different from formal relationships such as
volunteer activities, which also often convey public mean-
ing beyond the privacy of the dyad.
Relationship with spouses
The spousal relationship seems to be one of the most
important sources of social support among elders (Book-
wala & Franks, 2005; Okabayashi et al. 2004). However,
though negative impacts of conjugal bereavement are
commonly observed (Carr, 2004; Strohschein, McDo-
nough, Monette, & Shao, 2005; Wu & Hart, 2002), wid-
ows/widowers typically recover on standard measures of
mental health after about a year (Okabayashi et al., 1997),
and their health is not necessarily worse than married peo-
ple (Strohschein et al., 2005). Recent findings by Hughes
and Waite (2009) suggest that changes in marital status
are also often not associated with long-term deleterious
effects on some dimensions of health, such as depressive
tendency. These findings suggest that marital quality and
marital activities may be more important than the mar-
riage per se.
There are a few empirical studies that explicate
gender differences of the relationship between marital
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relationships and subjective well-being. Antonucci and
Akiyama (1987) found that relative to male elders female
elders had more emotional interactions with their children
and friends and fewer interactions with their husbands in
the U.S. It is interesting that even in the U.S. where the
relationship between husbands and wives are usually said
to be more equal than in Japan, male elders rely on their
spouses more heavily than do female elders. Antonucci
and Akiyama (1987) also found while female elders who
were satisfied with their husbands showed greater happi-
ness, the male elders did not. Male elders were benefi-
cially influenced by their friendships. This result was
somewhat contradictory because while happiness among
male elders relying heavily on wives was not affected by
marital satisfaction, happiness among female elders not
relying on their husbands was affected by marital satisfac-
tion. According to these authors, the reason why there
was no relation between marital satisfaction and happi-
ness among male elders was because of the small variance
of marital satisfaction. However, it may also be ascribed
to the gender differences of social expectations of tradi-
tional gender roles. That is, even if male elders were satis-
fied with high levels of support from their wives, they
might not appreciate it as much and might not feel quite
as happy because they consider such support as relatively
mundane or simply part of the “background.” On the con-
trary, even if female elders receive a relatively modest
amount of support from their husbands, they would be
very happy because they did not expect much support
from their husbands to begin with.
In Japan, Tsuchikura (2005) found that in middle-aged
couples, husbands rated seven indicators of marital quality
(marriage, spouse, attractiveness of spouse, happiness of
spouse, sexual life, pleasantness with spouse, and consola-
tion with spouse) higher than wives did. Then, she found
that the amount of time spent having pleasant conversa-
tions with one’s spouse was related to marital quality, but
only among wives, not husbands. Although she did not
directly examine the relation between marital quality and
subjective well-being, her findings suggest a positive
association. So, according to these two studies above, in
both Japan and the U.S., male elders rated their relation-
ships with their spouses higher in quality than female eld-
ers. But in both Japan and the U.S., well-being was likely
to be positively affected by one’s spouse only in the case
of female elders.
Relationships with adult children
For elders, adult children also seem to be an important
source of social support. Characteristics of the relation-
ship with their adult children include the number of chil-
dren, physical proximity to their domicile (or, although
becoming less common in Japan than in years past, co-
residence), frequency of contact with their children, and
the type of social support offered by this relationship,
such as emotional or instrumental.
In terms of co-residence with children or the number
of children, Silverstein, Cong, and Li (2006) found that in
rural areas in China, where co-residence is still common,
living with children and grandchildren fostered psycho-
logical well-being for grandparents, while living with
children only did not. One important reason for this is that
in the former environment elders receive greater financial
and emotional support from adult children than do those
in the latter. Silverstein et al. (2006) also found that the
number of children had beneficial effects on psychologi-
cal well-being among older parents in rural China. Cheng
and Chan (2006) found in China that there was no effect
of co-residence with children on filial discrepancy
between elders’ expectations and actual supportive behav-
ior from children. In the U.S., Byers, Levy, Allore, Bruce,
and Kasl (2008) found that there was no effect of the num-
ber of children on depressive tendency among middle-
aged and older people. In Spain, Zunzunegui, B
eland, and
Otero (2001) found that elderly widows/widowers who
were not living with their children showed higher levels
of depressive tendencies than those living with their chil-
dren. One cross-national study between the U.S. and
Japan found that the presence of adult children was asso-
ciated with fewer depressive tendencies among elders in
Japan only, and this effect was significantly stronger
among those who were unmarried as opposed to those
who were married (Sugisawa, Shibata, Hougham, Sugi-
hara, & Liang, 2002).
In terms of social support from adult children, Oka-
bayashi et al. (2004) also found that emotional support
from adult children had beneficial effects on the mental
health of older parents in Japan, especially among those
without spouses. Cheng and Chan (2006) found that in
China, adult children’s respect for their elderly parents
was beneficially related to elders’ well-being. In Spain,
Zunzunegui, B
eland, and Otero (2001) found that emo-
tional support from children played an important role in
maintaining the physical and mental health of elders. In
the U.S., Byers et al. (2008) found that adult children’s
reliance on instrumental support from their middle- and
old-age parents — and the corresponding parental percep-
tion of the adult child’s gratitude — appeared to make the
parents feel themselves useful and was associated with
fewer depressive tendencies among the parents.
Interactions with friends
Friendships are typically more enjoyable and burdened
with fewer obligations than family ties (Lee & Shehan,
1989). Though emotional support from friends was not
related to elders’ well-being in a national representative
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sample in Japan (Okabayashi et al., 2004), this finding
may be incidental to measurement limitations; the net
effect of friends may not have been detected because the
“friends” category included not only friends but also rela-
tives other than spouses or children. Lee and Shehan
(1989) indicated that interactions with friends in a U.S.
sample tended to bolster feelings of self-worth, while
interactions with family members failed to have a similar
effect. The reason behind the beneficial effects of friend-
ship on self-worth is that friends tend to make intimate
and joyful relations without the obligations that relation-
ships with family members and participation in formal
organizations may involve. Fiori, Antonucci, and Cortina
(2006) also found that among five types of social networks
(nonfamily-restricted, non-friends, family, diverse, and
friends), depressive tendencies were highest for elders in
non-friends networks, and lowest for individuals in
diverse networks in the U.S.
Social participation
Participating in formal organizations is another way to
cultivate interpersonal relationships. It is different from
informal relationships like friendships and family rela-
tionships because the extra-individual (i.e., institutional)
component can help construct and maintain a larger sense
of meaning, which, in turn, may contribute more to elders’
self-esteem than do informal relationships.
Social activity in formal organizations was divided
into two categories: employed jobs and unpaid activities.
Most Japanese companies adopt a mandatory retirement
system and most workers have to retire from their full-
time jobs once they approach the age of 60. After that,
they can live on their public or private pension and sav-
ings, and some continue to work as part-time workers.
This working style for elders is sometimes called “bridge
employment” (Feldman, 1994). Jobs seem to be one of
the sources from which not only monetary support but
also social interactions and support are derived. However,
in case an elder has to work due to financial need, jobs
may not have the same beneficial effects on mental health.
Alternatively, elders may be participating in unpaid activ-
ities such as at senior centers or volunteer centers. Their
participation in these activities is often considered to be
among the most voluntary and non-obligatory types of
social interaction.
In the U.S., Hao (2008) showed that participants of
multiple occupational and volunteer activities enjoyed a
slower rate of mental health decline than single activity
participants among middle-aged or older people aged 55
to 66. In particular, full-employment and low-level volun-
teering had an independent protective effect against
declines in psychological well-being. An empirical study
of the effects of social participation on life satisfaction
among national elderly representative samples aged 60 or
older in Japan and the U.S. (Sugisawa & Akiyama, 2001)
found that while participation in community activities had
positive effects on life satisfaction among all but female
elders in the U.S., participation in paid jobs did not have
any significant effects on their life satisfaction in either
country, even after controlling for the degree of financial
poverty. A recent national representative survey of people
aged 55 to 64 in Japan (Sugihara, Sugisawa, Shibata, &
Harada, 2008) found that men engaging in more hours of
paid or volunteer work was related to lower levels of
depressive tendency, while for women, none of the social
participation activities (paid work, volunteer work) were
found to be independently linked with depressive ten-
dency. On the other hand, for Japanese females, engaging
in multiple roles such as volunteer activities with unpaid
housework, in comparison with doing only housework,
was related to lower depressive tendency. Some contra-
dictions between two Japanese studies about the effects of
paid jobs among men suggest that paid jobs may be more
attractive to middle-aged men under 60 years old than
male elders over 60 years old. Nevertheless, unpaid vol-
unteer activities seem to be beneficial for older adults
both in Japan and the US.
Current research
In our review, although several types of social interaction
among elders appear to be beneficial to various compo-
nents of mental health, it is not clear whether each source
is independently beneficial to temporal changes in subjec-
tive well-being over time. To the extent of our knowledge,
few or no studies have focused on trajectories of subjec-
tive well-being among Japanese elders using three-wave
panel data. The purpose of this study is to clarify gender
differences of various social interaction types and their
effects on subjective well-being over three years among
Japanese elders. For our purposes, we analyze elders who
had been married or those who had been in widowhood/
divorced over our three-year survey interval with at least
one adult child.
Hypotheses
As noted above, findings in the literature are somewhat
contradictory, especially about gender differences of
effects of social interactions among Japanese elders. How-
ever, we make tentative hypotheses to make clear our line
of thought in this study. We start with the idea that a
greater diversity in the sources of social interaction should
be beneficial for elders (Fiori et al., 2006). And, while
male elders are likely to rely heavily on their spouse as a
source of interaction, female elders have a more diverse
network consisting of children, friends, and other social
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activities (Iwao, 2008). The following five hypotheses are
created.
(1) First, subjective well-being would decline over
three years among all elders, although there would
be interindividual variability in the change rates
(House, Lantz, & Herd, 2005). In addition, male
elders would decline more rapidly than female
elders because female elders are likely to live lon-
ger than male elders.
(2) Second, elders having frequent conversations with
their spouses would enjoy higher levels of well-
being and would thus enjoy greater stability than
those having infrequent conversations with their
spouses or those without spouses (Tsuchikura,
2005). In addition, these effects would be greater
among husbands than among wives, because male
elders have been shown to be more dependent on
their spouses than female elders (Iwao, 2008),
although there are contradictory results in the lit-
erature showing beneficial spousal relations
among only female elders (Tsuchikura, 2005;
Antonucci & Akiyama, 1987).
(3) Third, elders living with the emotionally closest
adult child, or those living apart from the closest
adult child but having frequent contact with him/
her, would enjoy greater subjective well-being
and enjoy more stability than those having infre-
quent contact with him/her (Byers et al., 2008;
Okabayashi et al., 2004; Sugisawa et al., 2002;
Zunzunegui et al., 2001). In addition, the number
of adult children would have beneficial effects on
subjective well-being among elders (Silverstein
et al., 2006). Then, although there are few Japa-
nese studies examining gender differences of the
effects of children on elders, these effects would
be greater for female elders than male elders
because female elders are more likely to have
built stronger emotional bonds with their children
during their adulthood than males.
(4) Fourth, more interactions with friends would be
related to higher subjective well-being and a more
stable rate of change among elders (Fiori et al.,
2006; Lee & Shehan, 1989). Although there are
few Japanese studies examining gender differen-
ces of effects of friends, female elders are more
likely to be influenced by their friendships than
males because female elders would be more likely
to place more weight on other sources of support
besides spouses.
(5) Fifth, elders participating in unpaid social activi-
ties (Sugisawa & Akiyama, 2001) or working at
paid jobs (Hao, 2008; Sugihara et al., 2008) would
enjoy higher levels of well-being and enjoy more
stability than those not participating in these
activities or than those without jobs. Female eld-
ers are more likely to be beneficially influenced
by unpaid social activities because female elders
would place more weight on other resources of
support besides their spouses, while males are
more likely to be beneficially influenced only by
paid jobs (Sugihara et al., 2008) because of a life-
time history of acclimation to paid work as an
obligation.
Methods
Participants
In this study, 1,360 older adults aged 64 to 80 years were
randomly sampled from 20,301 people listed on an elec-
toral registry in Hino City, a suburban area in Tokyo, in
October 2002 using sampling with probability proportion-
ate to size (PPS). A mail survey was first conducted with
them in November 2002, from which 634 valid responses
were collected. Two years later in November 2004, the
first follow-up survey was conducted with these 634 eld-
ers, and 431 valid responses were collected. Then, one
year later in November 2005, a second follow-up survey
was conducted with the 431 elders, and 364 valid
responses were collected.
In terms of networks of spouses and children, the fol-
lowing groups were excluded because of insufficient sam-
ple sizes: those who had never married (n ¼5), those
whose marital status changed from married to widow/wid-
ower over the three years (n ¼11), and those who had no
children (n ¼34). An additional 86 cases having missing
values in variables to be analyzed were excluded. As a
result, at the initial survey, 498 responses from elderly
persons who had been married or who had been in widow-
hood/divorce over our three-year survey interval, with at
least one child were analyzed. Due to subject drop-out,
the number of valid responses decreased to 330 in the sur-
vey conducted two years after baseline and to 284 in the
three year survey, although with the modeling approach
used here, we are able to use data from all 498, 330, and
284 persons respectively.
Measurement
Subjective well-being
Subjective well-being consists of two components: satis-
faction with life and positive affect (Diener, 1984). In this
research, we used life satisfaction and depressive ten-
dency measures, respectively, for those constructs.
Although depressive tendency is one of many aspects of
mental health, they also seem to be considered affective
components of subjective well-being as opposed to posi-
tive affect. Life satisfaction was measured using 10 items
Aging & Mental Health 5
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selected from the 20-item Life Satisfaction Index-A (LSI-
A) developed by Neugarten, Havighurst, and Tobin
(1961). Each item asked about whether the participants
were satisfied about their own life or not and rated in 3
response categories: 3 (agree), 2 (not sure) and 1 (dis-
agree). Higher scores denote greater psychological well-
being. Cronbach’s alpha coefficients were .755, .738, and
.712 in the initial survey and those conducted two and
three years later, respectively.
Depressive tendency was measured using 11 items of
an abbreviated version (O’Hara, Kohout, & Wallace,
1985) of the Center for Epidemiologic Studies Depression
Scale (CES-D) (Radloff, 1977). Each item asked about
how often one experienced different kinds of depressive
tendency during the past week and was rated in 3 response
categories: 3 (frequently), 2 (sometimes), and 1 (not at
all). Higher scores denote greater psychological distress.
Cronbach’s alpha coefficients were .796, .799, and .736 in
the initial survey and those conducted two and three years
later, respectively.
Relationship with spouse
The spousal relationship was measured by the following
question: “How frequently do you enjoy conversations
with your spouse?” There were three alternatives: “often,”
“sometimes,” and “almost never.” We categorized the first
choice as elders having “frequent” conversations, and the
last two choices as elders having “infrequent” conversa-
tions. Two dummy variables were created. One variable
was whether elders have frequent conversations with their
spouses. The other was whether elders have infrequent
conversation with their spouses. Widows/widowers/the
divorced were set as a reference category for both.
Relationship with children
The number of children was measured and considered to
be one of the potential sources of support. In addition, the
quality of elders’ relationships with their emotionally
closest child was measured. The following two questions
were asked: “Do you live with the emotionally closest
child?” Second, “If you live apart from the closest child,
how often do you communicate with him/her (by phone,
letters, and visits)?” The relationship with the closest child
was divided into three categories: elders living with the
closest child, those living apart from the closest child but
maintaining frequent exchanges (greater than or equal to
two communications a month) with him/her, and those
living apart from the closest child and maintaining infre-
quent exchanges (less than or equal to one contact a
month) with him/her. Two dummy variables were created.
One variable was whether or not elders living apart from
the closest child had infrequent contact with the closest
child (less than or equal to once a month). The other vari-
able was whether elders living apart from the closest child
had frequent communication (more than or equal to twice
a month). Elders’ living with the closest child was set as
the reference category.
Friendship
The frequency of contact with intimate friends was mea-
sured by the following question: “How often do you com-
municate with your intimate friends by phone, visits, or
letters? (If you have multiple intimate friends, please
mention the total number).” In this case, “intimate”
friends were defined as those to whom elders could open
their hearts and express what was on their minds and what
they were concerned about. The following six response
alternatives were scored from 0 to 5: “never” (or elders
without any intimate friends), “less than once a month,”
“once a month,” “two or three times a month,” “once a
week,” and “more than twice a week.”
Social participation
Two variables were used to measure social participation:
one was participating in a “circle or senior center club”
and another was participating in “community activities
such as volunteer activities.” Three alternatives were
scored from 1 to 3: “almost never,” “sometimes,” and
“often,” respectively. The scores of both variables were
added and the combined score was used as an indicator of
social participation. Cronbach’s alpha coefficient was
.646 at baseline.
Job status was measured as a dummy variable that indi-
cated whether elders were: working ¼1 or not working ¼0.
Demographic variables
Gender was used as a dummy variable, where male ¼1
and female ¼0. Age was measured simply in years. Sub-
jective health was measured with the following four alter-
natives: “poor,” “somewhat poor,” “fair,” and “good,”
scored from 1 to 4, respectively. Subjective economic sta-
tus was measured with the following four alternatives:
“marginal,” “somewhat marginal,” “somewhat affluent,”
and “affluent” scored from 1 to 4, respectively.
Models of analysis
Growth curve modeling was used to plot the temporal tra-
jectories of life satisfaction and depressive tendency
among Japanese elders and to predict variance in these
trajectories attributable to different sources of social
interaction. We used the Hierarchical Linear Modeling,
Version 6 (HLM6), software of Raudenbush, Bryk,
Cheong, & Congdon (2004), to estimate the parameters of
these growth models.
HLM has several distinct advantages that address
challenges inherent to the analysis of dependent data from
6H. Okabayashi and G.W. Hougham
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repeated measurements. The Level-1 model estimated a
growth trajectory in each domain of subjective well-being
(life satisfaction and depressive tendency) for each indi-
vidual in the sample based on repeated measurements
over three years. Thus, for each domain of subjective
well-being, each individual’s trajectory was summarized
by a set of growth parameters. The values (e.g., an inter-
cept and a slope that represent change over time) of these
parameters vary across individuals and can be used as
outcomes in Level-2 analyses. Variation in growth can be
predicted from a set of specific person-level variables. In
HLM, the multiple observations on each individual are
viewed as nested within the person. This treatment of
multiple observations as nested allows the investigator to
proceed without difficulty when the number and spacing
of time points vary across cases (Raudenbush & Bryk,
2002). An unconditional (no predictor) model is presented
as follows:
Level 1: subjective well-being
ti
¼b
0i
þb
1i
TIME
ti
þr
ti
Level 2: b
0i
¼g
00
þu
0i
b
1i
¼g
10
þu
1i
subjective well-being
ti
¼subjective well-being at the
time of measurement tof
person i;
TIME
ti
¼time of measurement tof person i(0, 2,
or 3 year);
b
0i
¼intercept, level of well-being at the initial
survey of person i;
b
1i
¼slope, change rate of well-being per one year
of person i;
r
ti
¼residual at time tof person i;
g
00
¼grand mean of intercepts of the total sample;
g
10
¼grand mean of slopes of the total sample;
u
0i
¼random effect of person ion intercept of
well-being; and
u
1i
¼random effect of person ion slope of
well-being.
HLM methods also allow us to proceed with analysis
even though there are missing respondents or responses
across the longitudinal data collection. Therefore, we ana-
lyzed all valid responses from our participants who had
been married or had been in widowhood/divorce over the
three years with at least one child: 498 at Wave 1, 330 at
Wave 2, and 284 at Wave 3. A variable of years passed
since Wave 1 was created. Responses in Wave 1, Wave 2
and Wave 3 were scored 0, 2, and 3 respectively. The
coefficient of slope in this study means the change of
well-being over 1 year.
To test our central hypothesis, the model included
eight person-level predictors of different sources of social
interaction: working, degree of social participation, inter-
action with friends, number of children, two dummy vari-
ables for intimate children, two dummy variables for
frequency of conversation with spouse. Then, we added
gender and its interaction terms with all of these social
network variables. In addition, we include three demo-
graphic variables: age, subjective health status, and sub-
jective economic status as control variables. All the
values of predictor variables were measured at the initial
survey because this study focused on the linear growth
curve of subjective well-being and time-invariate effects
of social interactions.
Results
Gender differences of all the variables at the initial survey
(N¼498) are shown in Tables 1 and 2. Male elders were
more likely to have a living spouse and be employed,
while female elders are more likely to have frequent con-
tacts with their friends. Although there was a significant
difference of relationship with spouse by gender, this is
likely reflected by the fact that female elders are more
likely to lose their spouse than male elders, and the pro-
portion of elders having frequent conversation with
spouse was not substantially different by gender. That is,
Table 1. Mean differences of variables at the initial survey by gender (N¼498).
Male (n¼275) Female (n¼223)
Range M SD M SD t (496)
Age 64–80 70.22 3.85 70.34 4.10 .333
Health status
a)
1–4 3.14 .82 3.00 .73 1.963
Economic status
b)
1–4 2.71 .76 2.81 .72 1.519
Social participation
c)
1–3 1.54 .65 1.61 .69 1.258
Number of children 1–6 2.13 .76 2.08 .74 .794
Interaction with friends
d)
0–5 1.87 1.66 3.04 1.58 8.042

Life satisfaction 10–30 21.91 3.77 22.20 3.81 .849
Depressive tendency 11–33 15.38 3.42 15.81 3.64 1.370

p<.05,

p<.01,

p<.001
a) Note: Subjective health status was measured on a four-point scale, with “1” indicating “poor” health, and “4” indicating “good” health.
b) Note: Economic status was measured on a four point scale, with “1” indicating “marginal” and “4” indicating “affluent.”
c) Note: Social participation was measured on a three point scale, with “1” indicating “almost never,” and “3” indicating “often.”
d) Note: Interaction with friends was measured on a six-point scale, with “0” indicating “never,” and “5” indicating “more than twice a week.”
Aging & Mental Health 7
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if we exclude widows or widowers, the proportions of
those having frequent conversation with spouse were
47.7% for males and 44.3% for females. Female elders
were more likely than male elders to co-reside with their
child or to have frequent contacts with their child living
apart. In addition, the gender composition of this sample
at each wave was almost the same: The rates of male eld-
ers were 55.2% (male 275, female 223), 55.2% (male 182,
female 148), and 54.9% (male 156, female 128), at
Wave 1, Wave 2 and Wave 3 respectively.
Hierarchical linear modeling was conducted on a
repeated unbalanced data set over three time points. All
variables except for the dummy variables were centered
by subtracting their mean values. In terms of depressive
tendency, the results of the unconditional model showed
that while there was a significant fixed effect of the level
(b
0
¼15.62, p ＜.001), there was no significant fixed
effect of the slope (b
1
¼.066, p ¼.219), indicating no
overall change of depressive tendency over the three
years. In addition, the reliability estimates (λ) of the ran-
dom level 1 coefficients of level and slope were .717 and
.182, respectively. We also found significant random
effects on both intercept and the slope for depressive ten-
dency (t
00
¼8.895, p <.001; t
11
¼.198, p ¼.005). The
correlation between the level and slope of depressive ten-
dency was negative and large (r¼.543). Since there
was significant variance of both level and slope of depres-
sive tendency among individuals, effects of various social
interaction and their interaction with gender on well-being
can be estimated.
In the full model, all social relations, their interaction
terms with gender, and control variables were included as
independent variables. Their effects on the level and slope
of depressive tendency were estimated. Non-significant
paths were deleted one by one from its slope to intercept
and from higher-order to lower-order interaction terms. In
HLM, the equation of slope consists of interaction terms
between given variables and time (Raudenbush & Bryk,
2002). In terms of this order of deleting variables, we fol-
lowed the general rule that if there were higher order
terms in a regression equation, we shouldn’t omit their
lower order terms (Aiken & West, 1993, p. 61). The varia-
bles consisting of significant higher-order interactions
were not deleted, even if the lower-order term consisting
of those variables were not significant. Finally, a reduced
model was obtained (Table 3). The reduced model is bet-
ter than the full model in terms of parsimony because the
relative goodness of fit of the reduced model (model devi-
ance ¼5300.690, number of parameters ¼19) was not
significantly worse than that of the full model (model
deviance ¼5269.143, number of parameters ¼46; x
2
(27)
¼31.547, NS) and the effects of predictors are not sub-
stantially different from the full model. To the level of
depressive tendency at baseline, after controlling for
health and economic status, social participation (g¼
.371, p ¼.045), interaction with friends (g¼.231, p
¼.003), and the number of children (g¼.578, p ¼
.033) were negatively related. Including two dummy vari-
ables for conversation with spouse into this model showed
significant improvement (x
2
(2) ¼19.961, p <.001), and
elders having infrequent conversations with their spouses
had higher levels of depressive tendency (g¼.731, p ¼
.031) than those without a spouse or those having frequent
conversations with their spouses (Figure 1).
Regarding the slope of depressive tendency, there was
a significant interaction of gender with the number of chil-
dren (g¼.298, p ¼.028). Figure 2 shows that female
elders with more children (2.86, the mean value plus 1
SD) had lower depressive tendency at the initial survey
but depression increased over the course of this study,
while those with fewer children (1.36, the mean minus 1
SD) showed a relatively high and steady level of depres-
sive tendency. On the other hand, for male elders, there
was no effect of the number of children.
In terms of life satisfaction, the results of the uncondi-
tional model showed that there was a significant fixed
effect of its level (b
0
¼21.996, p <.001) and slope (b
1
¼
.161, p ¼.005). In addition, the reliability estimates (λ)
of the random level 1 coefficients of level and slope were
.686 and .022, respectively. It also showed that while
Table 2. Proportional differences by gender (%) (N¼498).
Male (n¼275) Female (n¼223) x
2
df
Spouse 93.1 67.7 51.303

1
Employed 35.3 8.1 47.232

1
Relationship with the most intimate child
Infrequent contact with the child living apart 24.7 15.2 8.127

2
Frequent contact with the child living apart 47.3 48.4
Living with the child 28.0 36.3
Relationship with spouse
Frequent conversation with spouse 44.4 30.0 53.495

2
Infrequent conversation with spouse 48.7 37.7
Widows/Widowers 6.9 32.3

p<.05,

p<.01,

p<.001
8H. Okabayashi and G.W. Hougham
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there was a significant random effect of its intercept (t
00
¼9.596, p <.001), there was no random effect of its
slope (t
11
¼.024, p >.500). The correlation between
level and slope of life satisfaction was negative and rela-
tively small (r¼.138).
Because there was a significant variance in the level of
life satisfaction among individuals, the effects of various
sources of social interaction on satisfaction was estimated.
In a full model, all the variables and their interaction
terms with gender were included as independent variables
and their effects on the level of life satisfaction were esti-
mated. Non-significant paths were deleted one by one
from higher-order to lower-order interaction terms. The
variables consisting of significant higher-order interaction
were not deleted, even if the lower-order term consisting
of those variables was not significant. Though there was a
marginal effect in the second-to-final model (not shown)
suggesting that elders having infrequent contact with the
closest child showed a lower level of life satisfaction than
those living with him or her (g¼0.779, p ¼.029), the
two dummy variables of the amount of contact with the
closest child living apart from the elders were deleted
because the total effects did not reach a significant level
(x
2
(2) ¼5.298, p ¼.069). So we deleted these two
Table 3. Estimation of level-2 predictors of depressive tendency.
Estimate SE t (df)p
Level of depressive tendency at an initial point
Intercept 15.709 .301 52.12 (488) .000
Gender (male ¼1, female ¼0) 0.456 .292 1.56 (488) .118
Health status 1.923 .179 10.75 (488) .000
Economic status 0.345 .164 2.10 (488) .036
Social Participation 0.371 .185 2.01 (488) .045
Interaction with friends 0.231 .076 3.06 (488) .003
The number of children 0.578 .271 2.13 (488) .033
Infrequent conversations with spouse
(infrequent conversations with spouse ¼1,
widows/widowers/divorced ¼0)
0.730 .339 2.16 (488) .031
Frequent conversations with spouse (frequent conversations
with spouse ¼1, widows/widowers/divorced ¼0)
0.418 .351 1.19 (488) .235
Gender the number of children 0.664 .359 1.85 (488) .064
Change rate of depressive tendency for one year
Intercept 0.158 .077 2.05 (493) .041
Gender (male ¼1, female ¼0) 0.155 .104 1.49 (493) .137
Health 0.224 .071 3.17 (493) .002
The number of children 0.284 .101 2.81 (493) .006
Gender the number of children 0.298 .135 2.20 (493) .028
Figure 1. Levels of depressive tendency by conversation with
spouse.
Figure 2. Change of depressive tendency over three years:
Interaction of gender and the number of children.
Aging & Mental Health 9
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variables from the equation. Finally, a reduced model was
obtained (Table 4). The reduced model is better than the
full model in terms of parsimony because the relative
goodness of fit of the reduced model (model deviance ¼
5483.010, number of parameters ¼15) was not signifi-
cantly worse than the one of full model (model deviance
¼5471.134, number of parameters ¼26; x
2
(11) ¼
11.876, NS) and the effects of predictors are not substan-
tially different from the full model. To the level of life sat-
isfaction at baseline, after controlling for health and
economic status, social participation (g¼.695, p ¼.001),
interaction with friends (g¼.204, p ¼.014), and the
number of children (g¼.854, p ¼.001) were positively
related. Including a set of the two dummy variables about
conversation with spouse improved this model signifi-
cantly (x
2
(2) ¼40.861, p <.001). Elders having frequent
conversations with their spouses showed higher life satis-
faction than those (g¼1.317, p ¼.001) who have lost a
spouse (widows/widowers/the divorced) or those having
infrequent conversations with their spouses (Figure 3).
There was also a significant interaction of gender with
the number of children (g¼.813, p ¼.017). In Figure 4,
female elders with more children showed higher life satis-
faction at baseline than those with fewer children. On the
other hand, for male elders, there was no effect of the
number of children.
Table 4. Estimation of level-2 predictors of life satisfaction.
Estimate SE t (df)p
Level of life satisfaction at an initial point
Intercept 21.739 .318 68.39 (488) .000
Gender (male ¼1, female ¼0) .001 .285 0.01 (488) .996
Health status 1.094 .175 6.26 (488) .000
Economic status 1.261 .180 7.02 (488) .000
Social participation .695 .204 3.41 (488) .001
Interaction with friends .204 .083 2.46 (488) .014
The number of children .854 .256 3.34 (488) .001
Infrequent conversations with spouse
(infrequent conversations with spouse ¼1,
widows/widowers/divorced ¼0)
.538 .373 1.44 (488) .150
Frequent conversations with spouse
(frequent conversations with spouse ¼1,
widows/widowers/divorced ¼0)
1.317 .388 3.40 (488) .001
Gender the number of children .813 .339 2.40 (488) .017
Change rate of life satisfaction for one year
Intercept .184 .055 3.31 (497) .001
Figure 3. Levels of life satisfaction by conversation with
spouse.
Figure 4. Levels of life satisfaction by gender and the number
of children.
10 H. Okabayashi and G.W. Hougham
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Discussion
First, we found that life satisfaction decreased over the
three year study period. Contrary to what might have been
expected under the so-called well-being paradox, where
subjective well-being remains relatively stable with age
(Schilling, 2006), elders in our sample declined in life
satisfaction over the three-year study period. The reason
why the overall satisfaction of the elderly with their own
lives was decreasing may be because their functional
limitations and disease burdens were increasing with
age (House, Lantz, & Herd, 2005). However, the average
depressive tendency was stable in this sample, while there
was significant variability in the rate of change with
age among elders. Though there were two factors (subjec-
tive health status and the interaction of gender with
number of children) related to the slopes of depressive
tendency, we did not find either were factors that pre-
vented any increase in depressive tendency. The effects of
health status may be artifactual and attributable to ceiling
effects in that measure. Since this scale had a small range,
from 1 to 4, and most elders rated their health status as
“good” (M¼3.07) at baseline, high scores at the initial
survey are likely to decrease over three years, while lower
scores have more room for upward movement. The inter-
action effect of gender and the number of children on
depressive tendency is hard to understand. While female
elders with more children showed lower depressive
tendency levels at baseline, their depressive tendency
increased over three years. Considering this result together
with our finding that female elders with more children
relative to those with fewer children reported higher life
satisfaction steadily over three years, this seemingly con-
tradictory finding in terms of depressive tendency may
have resulted from some deficit of our data collection or
analysis. For example, we can only estimate linear trajec-
tories from our three-wave data set, and our significant
dropout rate (43.0%) from Wave 1 (498) to Wave 3 (280),
either of which may be influencing our results. Further, as
Kendler et al. (2005) and others point out, the quality of
the relationship matters, and mere numerical count of
children may not give us a full picture of the protective or
depressogenic effects of the social relationship. However,
at this point, we cannot conclusively interpret this finding.
To estimate a more natural trajectory of depressive
tendency, data sets with a greater number of waves are
ultimately needed. As a result, although we can observe a
declining trajectory of subjective well-being among elders
over three years, none of the factors in this study appeared
to prevent the deterioration of subjective well-being with
increasing age. In addition to that, there were no gender
differences of trajectories of subjective well-being. Further
research is needed to detect those factors.
Second, in terms of relationships with spouses, elders
having only infrequent conversations with their spouses
showed higher levels of depressive tendency than either
those having frequent spousal conversations or those with-
out spouses (widows/widowers/the divorced). Addition-
ally, elders having frequent conversations with their
spouses showed higher levels of life satisfaction than
either those having infrequent spousal conversations or
those without spouses. Our hypothesis that marital activi-
ties such as conversations with spouses would be impor-
tant for subjective well-being among elders is supported.
Further, the quality of the marital relationship (as mea-
sured by spousal conversation) between husbands and
wives appears to be more important than the mere exis-
tence of the marital relationship itself. However, there
was no gender-difference of these effects, though it was
hypothesized that there would be a more beneficial effect
of spousal conversation for male elders, following the
argument of some observers (e.g., Iwao, 2008). In this
study, conversation with one’s spouse seems to be equally
important for both male and female elders in Japan. How-
ever, it is important to notice that more than half of the
Japanese married elders in our sample (53.6%, 218 out of
407 persons) were not conversing with their spouses at a
“satisfactory” level. It is not hard to surmise that to have a
happy life in old age, both male and female elders would
have a better chance of sustaining a good conversational
relationship with their spouse if they started in their early-
and middle-aged adulthood years. In this study, half of
these elders do well, but half do not.
Third, in terms of relationships with adult children,
there was a beneficial effect of the number of children on
subjective well-being among female elders only. Female
elders with more children showed lower levels of depres-
sive tendency and higher levels of life satisfaction, at least
at baseline, than those with fewer children, while for male
elders there was no such effect of the number of children.
In previous research in rural China, the number of chil-
dren had beneficial effects on subjective well-being
among elders in traditionally organized communities (Sil-
verstein et al., 2006). While Japan is one of the developed
countries of the world, it is also an East Asian country and
Confucian social norms remain an important part of con-
temporary society. In this light, family relationships might
be considered to be important, and older parents might be
said to have stronger connections with their adult children
in Japan than those in the United States, where positive
effects of adult children were not found (Sugisawa et al.,
2002). Further, Japanese female elders seem to have a
stronger commitment to their own family than Japanese
male elders, possibly because they have built strong bonds
with their children as a consequence of normative patterns
associated with traditional gender roles. As a result, the
number of children seems to have stronger effects on sub-
jective well-being of female rather than male elders.
There were no effects of co-residence or more frequent
interaction with the closest children, although the area
Aging & Mental Health 11
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where this survey was conducted is a suburban area in
Tokyo, and with a well-organized public transportation
system it is relatively convenient for elders to reside and
lead their own lives independently. Therefore, there may
be a reduced need to either live with adult children or to
see them often when they are relatively healthy. The num-
ber of children may represent a measure of the potential
source of social support in time of need when elders fall
sick or are involved in other challenging situations. If eld-
ers have more potential sources of support, this might pro-
vide them with a greater sense of relief and well-being. In
sum, given the representativeness of our sample, elders
living in suburban Tokyo seem to be capable of managing
their daily lives by themselves apart from their adult chil-
dren and without seeing them frequently. However, since
elderly parents may count on their children as potential
sources of support in time of need, the number of children
has an independent beneficial effect on subjective well-
being among elderly mothers.
The fourth and fifth hypotheses were partially sup-
ported. Elders with more interactions with friends showed
lower levels of depressive tendency and higher levels of
life satisfaction. Elders with more unpaid social activities
showed lower levels of depressive tendency and higher
levels of life satisfaction, while their professional pursuits
or a working job status did not confer any effects. Such
social activities as friendship and unpaid social participa-
tion, which are entered into voluntarily, are based on per-
sonal interests, and involve few obligations, had
beneficial effects on the mental health of elders. But there
were no gender-differences of effects of these activities
on well-being although we expected female elders would
enjoy greater beneficial effects of friendship or voluntary
activities, while male elders would enjoy greater benefi-
cial effects of paid work. Although female elders had
more frequent contact with friends than males, the effects
of friendship is similar for both male and female elders.
Although male elders are more likely to have paid jobs,
the effect of it was not significant.
Iwao (2008) described how wives were likely to enjoy
interactions with various sources of support such as their
children, friends, and voluntary social activities with those
other than their husbands, while male elders were likely to
over-rely on their wives and thereby potentially foster
their resentment. Iwao’s story seems to be somewhat
overstated; her dystopic view may not reflect the typical
relationship between Japanese husbands and wives, but an
extreme “worst case” scenario. In fact, female elders are
likely to have a more diverse network consisting of their
own children or friends than male elders. Female elders
with more children are likely to have higher levels of sub-
jective well-being, while males do not. However, for both
male and female elders, the spousal relationship seems to
be the most important source of social interaction, and
friendship and voluntary social activities are similarly
beneficial. Although there is much loose talk about lonely
elderly husbands in Japanese mass media, our findings
about old age in Japan suggest that husbands need wives,
and wives need husbands equally. To enjoy a happy life
in old age, our study suggests that both male and female
elders should build and maintain strong relationships with
their spouses and wide networks of children, friends, and
other potentially protective sources of social interaction.
Limitations
Our study has some limitations. Based on three-waves of
data, we can only estimate linear trajectories, which are at
best imperfect models of change in such complex human
functions as psychological well-being. This might be the
reason why the change in depressive tendency found
among female elders with more children appeared to be
unnatural, or that there was non-significant variability in
individual changes of life satisfaction. In addition, while
we can estimate the rate of change in subjective well-
being, we cannot determine the factors that prevent the
deterioration of subjective well-being among elders. How-
ever, by collecting and using more than three waves of
data we may be able to estimate more realistic trajectories
and therefore find even better answers for the questions
addressed in this study (Singer & Willett, 2003). It might
be pointed out that activities of daily living or other func-
tional status measures might have been controlled for,
which may have even greater impact on the relationship
between social interaction and change of well-being than
subjective health status has. In addition, although we did
not examine interactions of marital status with other social
interactions, such as adult children, we found interesting
findings as previous studies suggested (Zunzunegui et al.,
2001; Sugisawa et al., 2002). And, although this study
focused on the linear growth curve of subjective well-
being and time-invariate effects of social interactions,
other models to estimate time-variate effects of social
interactions are also possible. These limitations should be
addressed in the future.
Conclusion
Based on a three-wave panel survey over three years, we
clarified gender differences of social interactions and their
effects on changes in subjective well-being among Japa-
nese elders. Although the importance of the number of
children was demonstrated as a potential source of support
only for female elders, there were no other gender differ-
ences of effects of social interactions. Spousal conversa-
tion and voluntary social activities such as friendship
interactions and unpaid social participation seem to be
important for both male and female elders. The unique-
ness of social relations among Japanese elders due to tra-
ditional gender norms, compared to Western societies
12 H. Okabayashi and G.W. Hougham
Downloaded by [Meisei University], [Hideki Okabayashi] at 19:32 24 April 2013

such as the U.S., may not be as great as it once might have
been. There are few studies on temporal changes in sub-
jective well-being among Japanese elders, therefore, our
study provides one of the few empirical views of this phe-
nomenon. In future studies, it would also be desirable to
examine how to prevent or ameliorate deterioration of
subjective well-being among elders. Nevertheless, the
findings of this work so far suggest that even in a highly
industrialized developed country, maintaining voluntary
social ties in the community and high levels of communi-
cation with one’s spouse are manifestly associated with
good mental health outcomes.
Acknowledgements
The first author is supported in part by funding from Meisei Uni-
versity and a Grant-in-Aid for Science Research (C 21530700)
from the Ministry of Education, Culture, Sports, Science and
Technology, in Japan. The second author is supported by grants
from the National Institute on Aging (P30 AG036459-02) and
the National Cancer Institute (KM1 CA156717). The content is
solely the responsibility of the authors and does not necessarily
represent the official views of the National Cancer Institute or
the National Institutes of Health. The authors would like to thank
the research participants who gave generously of their time, the
students who assisted with data collection, and the anonymous
referees and editors who made many helpful suggestions to ear-
lier versions of the manuscript.
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