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The psychological construct of ‘ikigai’ reflects the sense of having a ‘reason for living’ and has been associated with various positive health-related outcomes. This study presents an English translation of the Ikigai-9, empirically explores the manifestation of ikigai in the UK, and outlines its associations with facets of well-being. Three hundred forty-nine participants self-reported levels of ikigai as well as state measures of mental well-being, depression, anxiety and stress. Confirmatory factor analysis did not support the original three-factor model, favouring instead a single-factor solution. Results indicated that above sex and age, ikigai predicted greater scores of mental well-being and lower scores of depression. The Ikigai-9 has high internal reliability and presents a logistically convenient measure of ikigai for English-speaking populations. However, further validation (e.g. test-retest reliability) is required to develop a better understanding of the potential protective role of ikigai in mental health.
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Running head: Ikigai, well-being, depression, anxiety, and stress
English translation and validation of the Ikigai-9 in a UK Sample: A brief report
Dean Fido1*, Yasuhiro Kotera1, & Kenichi Asano2
1 University of Derby Online Learning, University of Derby (UK)
2 Department of Psychological Counseling, Faculty of Human Sciences, Mejiro University,
Tokyo (Japan)
Correspondence concerning this article should be addressed to Dr. Dean Fido, University of
Derby Online Learning, University of Derby, Enterprise Centre, Bridge Street, Derby, DE1
3LD, UK.
Tel.: +44 (1332) 597861. Email: deanfido.psych@gmail.com
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Abstract
In Japanese culture, the psychological construct of ‘ikigaireflects the sense of having a
‘reason for living’ and has been associated with positive health-related outcomes such as
increased mortality. This study presents an English translation of the Ikigai-9, and for the first
time, empirically explores the manifestation of ikigai in a Western population as well as its
associations with facets of well-being. Three hundred and forty-nine participants from the
United Kingdom self-reported levels of ikigai as well as state measures of mental well-being,
depression, anxiety, and stress. Confirmatory factor analysis did not support the original
three-factor model, favouring instead a single-factor solution. Results indicated that when
controlling for effects of sex and age, ikigai predicted greater scores of mental well-being and
lower scores of depression, but not anxiety or stress. The Ikigai-9 has high internal reliability
and presents a logistically-convenient measure of ikigai for English-speaking populations.
However, further validation (e.g., test-retest reliability) as well as a better understanding of
the potential protective role of ikigai in mental health is required. Data, transparency files,
and supplementary materials are available here: [shorturl.at/kIP27], and a pre-print is
available here: [to be inserted].
Key words: ikigai; scale development; well-being; depression; anxiety, stress
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English translation and validation of the Ikigai-9 in a UK Sample: A brief report
1. Introduction
In Japanese culture, the term ikigai’ refers to having ‘purpose in lifeor a ‘reason for living’
(Mathews, 1996; Mori et al., 2017; Park, 2015). Although other translations exist, such as
those pertaining to the processes of realising’ or ‘gaining joy from’ such purpose (Toshirō,
Skrzypczak, & Snowden, 2003), scholars maintain that ikigai should be considered a
composite construct; encompassing meaning, motivations, and values in life (Kumano, 2012;
Weiss, Bass, Heimovitz, & Oka, 2005).
Recently, there has been a significant increase in the exploration of ikigai across areas of
positive-psychology and preventative-medicine (Buettner, 2017; García & Miralles, 2017),
with ikigai being considered a key predictor of physical and psychological well-being (Mori
et al., 2017; Weiss et al., 2005). At a cross-sectional level, having ikigai has been positively
associated with self-reported physical health in the elderly (Murata, Kondo, Tamakoshi,
Yatsuya, & Toyoshima, 2006) and negatively associated with psychological burden in their
carers (Okamoto & Harasawa, 2009). Moreover, the presence of ikigai has been consistently
shown to benefit facets of well-being and mortality across multiple, large-scale longitudinal
studies. Specifically, the presence of ikigai has been significantly associated with reduced
incidence of cardiovascular disease and stroke (Koizumi, Ito, Kaneko, & Motohashi, 2008
[13.3-year follow-up]; Tanno et al., 2009 [5-year follow-up]; Sone et al., 2008 [7-year
follow-up]), functional disability after controlling for symptoms of depression (Mori et al.,
2017 [12-year follow-up]), and other causes of mortality such as injury, lesions, and suicide
(Tanno et al., 2009). Regarding mortality as a consequence of cancer, converging evidence
suggests an absence of any association with ikigai after long-term follow-up (Sone et al.,
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2008; Tanno et al., 2009), however one study did identify an inverse relationship between
ikigai and breast cancer, more specifically, elsewhere (Wakai et al., 2007). Importantly, the
precise mechanism underpinning the benefit of ikigai on well-being remains unknown.
One key limitation of this literature, however, is the categorical nature by which ikigai is
measured (Okamoto & Harasawa, 2009; Murata et al., 2006; Sone et al., 2008; Tanno et al.,
2009). If we are to believe the complex and multifaceted conceptualisation of ikigai
(Mathews, 1996), then simply confirming or rejecting a static state of ikigai neither seems
appropriate nor useful in terms of exploring ikigai as a psychological construct. The Ikigai-9
(Imai, Osada, & Nishi, 2012) is a psychometric tool published and validated only in
Japanese, that has been proposed as a means of measuring ikigai across the dimensions of [1]
optimistic and positive emotions toward life, [2] active and positive attitudes towards one's
future, and [3] acknowledgment of the meaning of one's existence. Although other measures
of ikigai exist, these are either limited in terms of their narrow response options, leading to
reduced variance in data (Kondo & Kamada, 2003), or are heavily orientated towards the
enjoyment of leisure pursuits and free time, and so not fully encapsulating the most common
definitions of the experience of ikigai (Kono, Walker, Ito, & Hagi, 2019).
Although the potential importance of ikigai appears to be pervasive across core health and
well-being outcomes, current empirical literature is restricted to middle-aged or elderly
Japanese samples, with no indication as to the manifestations or correlates of ikigai in
Western populations. Commentaries of the potential importance of ikigai have begun to reach
the United Kingdom (UK) through conceptual books (García, Miralles, & Cleary, 2017;
Matthews, 1996) and written media (Barr, 2018; Ough, 2017), however there currently exists
no published empirical research exploring the presence of ikigai in Western populations. In
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part, this is likely a result of the absence of an English-language tool enabling such research.
As such, the aim of this study was to translate the Ikigai-9 into English and subsequently
validate it within a population derived from the UK. Further, we sought to delineate baseline
associations between ikigai and aspects of mental health; hypothesising a positive association
with well-being, and negative associations with measures of depression, anxiety, and stress.
2. Methods
2.1. Participants and procedure
In line with guidelines for individual differences researchers (Gignac, & Szodoraim
2016), an a priori power analysis (f2 = .03, α = .05) determined around 368 participants were
required to have 80% power in the planned analyses (G*Power, v3.1). Three hundred and
forty-nine participants (Mage = 34.68 years, SD = 12.01 years; RNGage = 18-72 years; 50.7%
female), all originating from the UK, completed an online questionnaire advertised through
Prolific; a crowdsourcing website whose data quality is considered comparable to that
obtained via face-to-face means (Peer, Brandimarte, Samat, & Acquisti, 2017). On average,
the study took around 10 minutes to complete, and participants provided written informed
consent in accordance with approved central university research protocols by ticking a box on
both the first and last pages of the survey. All completers were reimbursed with £0.85 for
their participation.
2.2. Materials
The Ikigai-9 (Imai et al., 2012) consists of nine items measuring one’s reason for
being through dimensions of emotions towards one’s life, attitudes towards one’s future, and
the acknowledgement of one’s existence. The Ikigai-9 was translated from Japanese into
English by KA, before being back-translated by YK. Both KA and YK are bilingual, and any
discrepancies in translation were resolved through discussion. Participants are asked to rate
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whether each statement applies to them on a five-point scale (1 = Does not apply to me, 5 =
Applies to me a lot).
The Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS; Stewart-
Brown et al., 2009) consists of seven items measuring recent (i.e., past two weeks)
psychological functioning and emotional and mental wellbeing. Participants are asked to rate
their experience of each statement on a five-point scale (1 = None of the time, 5 = All of the
time).
The Depression Anxiety Stress Scales (DASS-21; Lovibond & Lovibond, 1995)
consists of 21 items reflecting recent (i.e., past week) tendency to feel depression, anxiety,
and stress. Participants are asked to rate their experience of each statement on a four-point
scale (0 = Never, 3 = Almost Always).
3. Results
3.1. Construct validity of the Ikigai-9
A confirmatory factor analysis of the three-factor solution of the Ikigai-9 showed that
the data did not fit the model outlined in Imai et al. (2012): χ²(24) = 186.73, p < .001,
RMSEA = .14, CFI = .91, TLI = .87 (cut off values provided by Hu & Bentler, 1999; see
Supplementary Data). As such, we computed a principal axis factor analysis with varimax
rotation on all nine items. Bartlett’s test of sphericity was significant, p < .001, and the
Kaiser-Meyer-Olkin measure verified the sampling adequacy for the analysis, KMO = .88,
with all KMO values for individual items greater than .80; well above the acceptable limit of
.50. Convergence of the scree plot and eigenvalues over Kaiser’s criterion of 1, suggested a
single factor structure explaining 56.10% of the variance. This single factor model was used
for subsequent analyses. Table 1 shows the factor loadings after rotation.
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3.2. Sex differences in questionnaire measures
Independent t-tests were used to delineate sex differences within our sample; means
and standard deviations for questionnaire data are reported in Table 2. On average, males
were older, t(347) = 2.83, p = .01, d = .30, and reported greater levels of depression t(347) =
4.66, p < .001, d = .50, than female participants. There were no significant differences in
scores on measures of ikigai, well-being, anxiety, or stress.
Table 1. Exploratory factor analysis of the Ikigai-9 (n = 349)
Factor 1
9. I believe that I have some impact on someone.
.84
7. My life is mentally rich and fulfilled.
.78
5. I am interested in many things.
.76
3. I feel that I am contributing to someone or the society.
.75
8. I would like to develop myself.
.73
1. I often feel that I am happy.
.73
6. I think that my existence is needed by something or someone.
.71
2. I would like to learn something new or start something.
.69
4. I have room in my mind.
.46
Eigenvalues
5.05
% of variance
56.10
α
.90
Table 2. Descriptive statistics for questionnaire scores with between sex comparisons.
α
Total
M (SD)
M (SD)
Females (n = 177)
M (SD)
p
Age
-
34.68 (12.01)
32.90 (11.70)
.01
Ikigai
.90
32.87 (7.91)
33.33 (8.37)
.26
Well-being
.88
22.79 (5.12)
23.32 (4.73)
.05
Depression
.93
25.72 (11.19)
22.60 (10.21)
< .001
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3.3. Concurrent validity: prediction of well-being, depression, anxiety, and stress
Although not correlated with measures of anxiety or stress, scores on ikigai correlated
positively with well-being and negatively with depression. Scores on depression, anxiety, and
stress were all positively correlated with one another and negatively correlated with well-
being (see Table 3). Next, we conducted four hierarchical multiple regression analyses. In
each analysis, age and sex (0 = male, 1 = female) were entered at step one, and ikigai was
entered at step two. The dependant variables were scores on well-being, depression, anxiety,
and stress. All models met the assumptions required for hierarchical multiple regression
analysis.
In step 1, sex and age positively contributed to the prediction of well-being, and
negatively contributed to the prediction of depression and anxiety. Only age significantly
(negatively) contributed to the prediction of stress. In addition to these findings holding at
step 2, introducing scores on ikigai explained an additional 15% of variation in well-being
(positive association) and 2% of variation in depression (negative association). There were no
significant increases in the explained variances of anxiety or stress (see Table 3).
[Table 3 around here currently at the end of document]
4. Discussion
The notion of having ikigai – a “reason for living” (Mathews, 1996) has been associated
with a series of health-related outcomes including the absence of psychological burden and
decreased mortality rates. Findings are consistent and often derived from large-scale
Anxiety
.86
22.10 (9.11)
21.16 (9.51)
.05
Stress
.88
27.49 (9.67)
27.33 (10.00)
.76
Note. Significant differences highlighted in bold.
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longitudinal research; however, current literature is restricted to Japanese samples with no
psychometric tools available to empirically test or understand ikigai in English-speaking
cohorts. For that reason, this study aimed to translate, and subsequently validate, the Ikigai-9
in an English-speaking sample derived from the UK.
Confirmatory factor analysis of the English version of the Ikigai-9 did not support the three-
dimensional structure originally proposed in Imai et al. (2012). Instead of comprising the
facets of optimistic and positive emotions toward life, positive attitudes towards one's future,
and acknowledgment of the meaning of one's existence, data reported in this study favoured a
single factor solution of ikigai, which explained 56.10% of the variance with high internal
consistency (α = .90). As such, it appears that although ikigai might be described through
overlapping notions of motivations and values pertaining to life (Kumano, 2012; Weiss, Bass,
Heimovitz, & Oka, 2005), such facets cannot be teased apart in a meaningful way, at least in
this first cohort to complete the English version of the Ikigai-9.
Analyses of concurrent validity in this study outlined associations between self-reported
ikigai and indices of psychological health including greater mental well-being and lower state
depression. Such findings, in addition to the strong psychometric properties of the English
version of the Ikigai-9, lend support for the usefulness of this measure in subsequent
exploration of the potential protective benefits of ikigai; unrestricted to the Japanese
population. This is important due to the global prevalence of depression thought to impact the
lives of more than 300 million people worldwide; contributing to higher incidence of suicide
as well as wider financial and resource implications for health care professionals (World
Health Organization, 2018). Japanese suicide prevention policies aim to enhance ikigai in
people to reduce the number of suicides (Ministry of Health and Labour Welfare, 2017).
Suicide has previously been negatively associated with the presence of ikigai (Tanno et al.,
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2009), however it remains unknown whether this association might be mediated in part
through depression. Important to note, is the admittedly small but significant effect size of the
contribution of ikigai to the depression model. Moreover, although not explicitly explored
here, ikigai is consistently associated with reduced risk of cardiovascular disease in Japanese
samples (Koizumi et al., 2008; Tanno et al., 2009; Sone et al., 2008). Owing to the UK’s
National Health Service (2019) identifying cardiovascular disease as a clinical priority over
the next 10 years of health care provisions – with the aim of preventing 150,000 heart attacks
- the ability to test the prospective protective effect of ikigai in the UK is a timely resource.
Interestingly, what were not identified were any associations between ikigai and self-report
measures of anxiety or stress. Such associations have not previously been explored (or at
least, published) in Japanese cohorts, which might indicate that ikigai plays little-to-no roll in
anxiety or stress. However, as psychometric measures reported in this investigation were
state measures, it is possible that ikigai might play a protective role whereby feelings of
anxiety, stress, and indeed depression are attenuated when individuals are faced with
situations that would normally evoke such states. In addition to experimental research being
required to test these hypotheses, understanding is needed as to the mechanism by which
ikigai might underpin health-related benefits. For example, Tanno et al. (2009) hypothesised
that ikigai may be associated with positive health-related behaviours (e.g., reduced smoking
and drinking) and psychosocial factors (e.g., living with a spouse and having a fulfilling job).
Results are discussed in light of some limitations. First, this is a cross-sectional study of a UK
general population and so we can neither make any direct comparisons between the
experience of ikigai in Eastern or Western civilisations, nor infer causation from the
correlations presented, while noting that our scores were similar to 428 Japanese people
(33.1±5.4 years for 128 males, 33.4±5.4 years for 300 females, and 33.3±5.3 years in total;
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Imai et al., 2012). Second, this is the first time the English version of the Ikigai-9 has been
tested, and so to compound and further validate our understanding of associations outlined
above, further pre-registered replications are essential. Third, the ikigai measure was only
administered at a single time-point, and so we are not able to state that this measure is stable
across time.
In conclusion, the translation and validation of the Ikigai-9 reported here provides an initial
step in aiding our understanding of the manifestation and associated mental health-related
correlates throughout the West. Importantly, future research should seek to replicate this data
inside and outside of the UK, as well as establish both the mechanisms by which ikigai might
bring about – or protect – mental and physical well-being, and also whether ikigai is
malleable to change. If one can obtain or develop ikigai, then it would be possible to develop
interventions aimed at increasing ikigai as a means of supporting established health-care
measures.
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Acknowledgements
This work was funded by departmental funding awarded to DF and YK by the University of
Derby.
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Table 3. Correlations and standardized regression coefficients between ikigai, well-being, depression, anxiety, and stress.
Well-being
Depression
Anxiety
Stress
Correlations
Ikigai
Well-being
Depression
Anxiety
Stress
.40***
-
-.14**
-.59***
-
.04
-.35***
.68***
-
.04
-.43***
.71***
.77***
-
Standardized regression coefficients
Step 1 Sex
.14**
[.33, 2.46]
-.26***
[-8.14, -3.54]
-.14**
[-4.41, -.63]
-.04
[-2.76, 1.34]
Age
.21***
[.04, .13]
-.12*
[-.21, -.02]
-.22***
[-.25, -.09]
-.14*
[-.20, -.02]
Model
F(2,346) = 9.64, p < .001
F(2,346) = 13.81, p < .001
F(2,346) = 11.09, p < .001
F(2,346) = 3.22, p = .04
R2
.05
.07
.06
.02
Step 2
Sex
.11*
[.16, 2.12]
-.25***
[-7.95, -3.31]
-.14**
[-4.47, -.70]
-.04
[-2.82, 1.29]
Age
.20***
[.04, .12]
-.12*
[-.21, -.02]
-.23***
[-.25, -.09]
-.14*
[-.20, -03]
Ikigai
.39***
[.19, .31]
-.13*
[-.32, -.03]
.06
[-.06, .18]
.04
[-.08, .18]
Model
F(1,345) = 64.53, p < .001
F(1,345) = 5.95, p = .02
F(1,345) = 1.12, p = .29
F(1,345) = .65, p = .42
R2
.20
.09
.06
.02
... A recent study translated the Ikigai-9 into English and validated this version [13]. Other very recent validation studies stem from France [14] and Turkey (preprint: [15]). ...
... Similar to prior research (e.g., [13][14][15]), pairwise correlations of the Ikigai-9-G with life satisfaction, happiness, health-related quality of life, depressive symptoms, and anxiety symptoms were calculated. ...
... This is crucial for maintaining the usefulness of the instrument and the validity of the results obtained. A very recent study confirmed a three-factor structure of the Ikigai-9 in France [14], whereas two other studies (UK [13] and Turkey [15]) favored a 1-factor solution (e.g., confirmatory factor analysis of the three-factor solution in UK: RMSEA = 0.14, CFI = 0.91, TLI = 0.87 [13])). ...
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Background: The Japanese concept of “ikigai” embodies the feeling of having a meaningful purpose in life. It is associated with several positive outcomes. This study aimed to translate and validate the German version of the Ikigai-9 scale (Ikigai-9-G)—and ikigai scores for certain groups of interest were presented. Methods: Data were taken from a quota sample of the German adult population aged 18 to 74 years (n = 5000; representative in terms of age, sex, and state). Data were collected in August/September 2023. The translation process was conducted in accordance with the existing guidelines. Reliability (Cronbach’s alpha; McDonald’s omega) was assessed. Moreover, we evaluated the structure’s soundness using confirmatory factor analysis for construct validity and examined concurrent validity by exploring pairwise correlations between the Ikigai-9-G with life satisfaction, happiness, health-related quality of life, depressive symptoms, and anxiety symptoms. Additionally, we presented ikigai scores for specific sociodemographic groups of interest. Results: Cronbach’s alpha for the Ikigai-9-G equaled 0.88. The results of confirmatory factor analysis supported the original three-factor model as initially proposed. A higher sense of ikigai was associated with less depressive symptoms (r = −0.43, p < 0.001), less anxiety symptoms (r = −0.39, p < 0.001), higher health-related quality of life (r = 0.42, p < 0.001), higher happiness levels (r = 0.62, p < 0.001), and higher satisfaction with life levels (r = 0.57, p < 0.001). Conclusion: The Ikigai-9 scale is a psychometrically sound tool offering the possibility for assessing ikigai among German speakers. Additional translation and validation studies are required to facilitate comparisons across different countries.
... Our results showed that both men and women with Ikigai had a lower prevalence of depression than those without Ikigai. This is supported by a study examining the association between Ikigai and depression, which found that the level of Ikigai was positively correlated with well-being and inversely correlated with depression [39]. Indeed, the development of positive emotions has been found to result in better psychological function and reduce depression [40]. ...
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Background Having positive psychological well-being has been associated with serum high-density lipoprotein cholesterol (HDLC), but no longitudinal study to date has examined the association between Ikigai and serum HDLC. Therefore, we examined the association between Ikigai and change in serum HDLC over time using a cohort dataset spanning 2010–2018. Methods The study included 471 men and 776 women aged 40–74 years who underwent a cardiovascular examination in 2010 and were asked their levels of Ikigai. We combined “definitely yes” and “yes” as “with Ikigai” and recorded “a little” as “with a little Ikigai” and “no” as “without Ikigai”. We measured serum HDLC using direct methods. The association between Ikigai and serum HDLC levels at baseline, and changes in this relationship during an eight-year period, were analyzed using linear mixed-effect models. Results At the baseline, relative to those without Ikigai, women with Ikigai had higher serum HDLC (baseline difference in those with a little Ikigai = 7.52 mg/dl, 95% confidence interval [CI]: 1.12 to 13.9 and in those with Ikigai = 8.11 mg/dl, 95% CI: 1.54 to 14.7). The difference in serum HDLC between women with and without Ikigai remained over the eight-year follow-up period. There were no similar Ikigai-associated differences in the serum HDLC of men. Conclusions Women with Ikigai showed differences in serum HDLC that were observed at baseline and persisted over time.
... This influenced many of his actions that laid the groundwork for his leadership, including living a life of simplicity and free from dishonesty [46]. Ikigai is often described as a state of balance and psychological well-being, which lays the foundation for one to seek out challenges, and in turn enhance the experience of their daily life [60,61]. Yozan's motivation to lead the people of Yonezawa was largely driven by his desire to rebuild his estate and help them break out of poverty [46]. ...
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... Due to its cultural nuances, researchers argue that no single English word exists to capture the entirety of ikigai concept (Lomas, 2016). However, researchers typically understand ikigai as compatible with life's meaning and purpose (Fido et al., 2020;Kumano, 2018;Lomas, 2016). The concept of ikigai includes the feeling of meaning and purpose in life, and describes an activity that evokes feelings of meaning and purpose (Kamiya, 1996;Kumano, 2018). ...
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The concept of Ikigai is booming, as more and more people worldwide are turning to the question of what constitutes the meaning of life. In Western literature, it has become established to define Ikigai as what one is good at and what one is paid for. This forces Ikigai into the context of a performance and self-optimization culture, bypassing the original content of the term, which literally means “value of life”. As a key cultural concept, a precise understanding of Ikigai is closely linked to understanding its sources and cultural foundations. It is an expression of a society that lives in the here and now, where the individual is closely connected to the community, where death is perceived as a natural part of life, and where everyday life is not only seen as a process of fulfilling necessities but also as a place of meditation. Only by engaging with the backgrounds of Ikigai can one understand what the essence of Ikigai is and where or how the understanding of Ikigai can vary without distorting its actual meaning.
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Resumen Se describe el término ikigai que desde finales de los años 50 es amplia-mente utilizado en Japón en las ciencias de la salud como "sentido de la vida" tanto en investigaciones con enfermos crónicos como en adul-tos mayores. Se destaca su importancia y sus semejanzas y diferencias con bienestar hedónico y eudaimónico. Finalmente, se deja abierta la pregunta sobre su existencia fuera del contexto social y cultural de las islas japonesas. Abstracts The term ikigai is described, which since the late 1950s has been widely used in Japan in the health sciences as "meaning of life" in research with both the chronically ill and the elderly. The importance of the term and its similarities and differences with hedonic and eudaimonic well-being are highlighted. Finally, the question of its existence outside the social and cultural context of the Japanese islands is left open.
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In order to classify the caregivers at high risk of increase in their burden early, linear discriminant analysis was performed to obtain an effective discriminant model for differentiation of the presence or absence of increase in caregiver burden. The data obtained by self-administered questionnaire from 193 caregivers of frail elderly from January to February of 2005 were used. The discriminant analysis yielded a statistically significant function explaining 35.0% (Rc=0.59; d.f.=6; p=0.0001). The configuration indicated that the psychological predictors of change in caregiver burden with much perceived stress (1.47), high caregiver burden at baseline (1.28), emotional control (0.75), effort to achieve (-0.28), symptomatic depression (0.20) and "ikigai" (purpose in life) (0.18) made statistically significant contributions to the differentiation between no increase and increase in caregiver burden. The discriminant function showed a sensitivity of 86% and specificity of 81%, and successfully classified 83% of the caregivers. The function at baseline is a simple and useful method for screening of an increase in caregiver burden among caregivers for the frail elderly at home.