{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T04:54:04Z","timestamp":1791262444424,"version":"4.1.0"},"reference-count":40,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T00:00:00Z","timestamp":1791244800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Higher-level functional capacity (HLFC) may capture functional vulnerability beyond basic activities of daily living in older adults. However, the association of baseline HLFC with subsequent incident long-term care insurance (LTCI) certification remains unclear when death is considered a competing event.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This prospective cohort study included 688 community-dwelling Japanese adults aged 65\u202fyears or older who participated in the 2017 wave of the Community Empowerment and Care for Well-being and Healthy Longevity Study. HLFC was assessed once at baseline using the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC), including the total score and the formal subdomain scores for Instrumental Self-Maintenance, Intellectual Activity, and Social Role. Participants were followed for 8\u202fyears. Incident LTCI certification at Support Level 1 or higher was analyzed using Fine\u2013Gray competing-risk regression, with death before certification treated as a competing event. The fully adjusted Fine\u2013Gray model included age group, sex, living arrangement, physical activity, smoking status, alcohol consumption, and disease status.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 688 complete-case participants, 145 developed incident LTCI certification and 79 died before certification. In the fully adjusted model, higher HLFC total score was associated with a lower cumulative incidence of incident LTCI certification (sHR per 1-point increase, 0.941; 95% CI, 0.891\u20130.994;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.029). Higher Social Role score was also associated with a lower cumulative incidence (sHR, 0.803; 95% CI, 0.702\u20130.918;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.001), whereas the continuous per-point Instrumental Self-Maintenance and Intellectual Activity estimates included the null after full adjustment. Multiple-imputation and lagged-event analyses generally retained the direction and broad magnitude of the complete-case estimates. Exposure-by-log(time) diagnostics indicated that the Fine-Gray associations varied over follow-up. Estimates also varied under alternative age specifications, with particularly marked attenuation of the total-score association.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Higher baseline HLFC total and Social Role scores were associated with a lower subsequent cumulative incidence of incident LTCI certification in the prespecified age-group-adjusted analysis. The total-score association was substantially attenuated under alternative age adjustments, while the magnitude of the Social Role association also varied.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1950765","type":"journal-article","created":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T04:25:58Z","timestamp":1791260758000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Higher-level functional capacity and incident long-term care insurance certification: a competing risks analysis"],"prefix":"10.3389","volume":"14","author":[{"given":"Meiling","family":"Qian","sequence":"first","affiliation":[{"name":"Graduate School of Comprehensive Human Sciences, University of Tsukuba","place":["Tsukuba, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jinrui","family":"Zhang","sequence":"additional","affiliation":[{"name":"Graduate School of Comprehensive Human Sciences, University of Tsukuba","place":["Tsukuba, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shuanghong","family":"Li","sequence":"additional","affiliation":[{"name":"Graduate School of Comprehensive Human Sciences, University of Tsukuba","place":["Tsukuba, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maiko","family":"Shigeeda","sequence":"additional","affiliation":[{"name":"Graduate School of Comprehensive Human Sciences, University of Tsukuba","place":["Tsukuba, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haotian","family":"Gao","sequence":"additional","affiliation":[{"name":"Graduate School of Comprehensive Human Sciences, University of Tsukuba","place":["Tsukuba, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruifeng","family":"Zhao","sequence":"additional","affiliation":[{"name":"Graduate School of Comprehensive Human Sciences, University of Tsukuba","place":["Tsukuba, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mengxuan","family":"Wang","sequence":"additional","affiliation":[{"name":"Graduate School of Comprehensive Human Sciences, University of Tsukuba","place":["Tsukuba, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dandan","family":"Jiao","sequence":"additional","affiliation":[{"name":"Department of Nursing, The First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology","place":["Luoyang, Henan, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuko","family":"Sawada","sequence":"additional","affiliation":[{"name":"Department of Physical Therapy, Morinomiya University of Medical Sciences","place":["Osaka, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akihiro","family":"Kakuda","sequence":"additional","affiliation":[{"name":"Department of Physical Therapy, Morinomiya University of Medical Sciences","place":["Osaka, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hiroshi","family":"Kinoshita","sequence":"additional","affiliation":[{"name":"Department of Public Welfare","place":["Tobishima, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rika","family":"Okumura","sequence":"additional","affiliation":[{"name":"Department of Public Welfare","place":["Tobishima, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuriko","family":"Kawasaki","sequence":"additional","affiliation":[{"name":"Department of Public Welfare","place":["Tobishima, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tokie","family":"Anme","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Tsukuba","place":["Tsukuba, Ibaraki, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,10,6]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"26","DOI":"10.1377\/hlthaff.19.3.26","article-title":"Long-term care insurance comes to Japan","volume":"19","author":"Campbell","year":"2000","journal-title":"Health Aff (Millwood)"},{"key":"ref2","year":"2024"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"1183","DOI":"10.1016\/S0140-6736(11)61176-8","article-title":"Population ageing and wellbeing: lessons from Japan\u2019s long-term care insurance policy","volume":"378","author":"Tamiya","year":"2011","journal-title":"Lancet"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"10523","DOI":"10.3390\/ijerph181910523","article-title":"Complex multimorbidity and incidence of long-term care needs in Japan: a prospective cohort study","volume":"18","author":"Kato","year":"2021","journal-title":"Int J Environ Res Public Health"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"2162","DOI":"10.3390\/ijerph19042162","article-title":"Risk factors of long-term care insurance certification in Japan: a scoping review","volume":"19","author":"Takahashi","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1186\/s12877-020-01968-z","article-title":"Predicting incidence of long-term care insurance certification in Japan with the Kihon checklist for frailty screening tool: analysis of local government survey data","volume":"21","author":"Ito","year":"2021","journal-title":"BMC Geriatr"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"271","DOI":"10.1007\/s12126-011-9109-0","article-title":"National long-term care insurance policy in Japan a decade after implementation: some lessons for aging countries","volume":"37","author":"Yong","year":"2012","journal-title":"Ageing Int"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"67","DOI":"10.31662\/jmaj.2018-0015","article-title":"The long-term care insurance system in Japan: past, present, and future","volume":"2","author":"Iwagami","year":"2019","journal-title":"JMA J"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"179","DOI":"10.1093\/geront\/9.3_Part_1.179","article-title":"Assessment of older people: self-maintaining and instrumental activities of daily living","volume":"9","author":"Lawton","year":"1969","journal-title":"Gerontologist"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/0277-9536(94)90294-1","article-title":"The disablement process","volume":"38","author":"Verbrugge","year":"1994","journal-title":"Soc Sci Med"},{"key":"ref11","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1037\/10044-020","volume-title":"The Psychology of Adult Development and Aging","author":"Lawton","year":"1973"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1016\/0167-4943(91)90053-S","article-title":"Measurement of competence: reliability and validity of the TMIG index of competence","volume":"13","author":"Koyano","year":"1991","journal-title":"Arch Gerontol Geriatr"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"141","DOI":"10.1016\/S0167-4943(02)00081-X","article-title":"Longitudinal changes in higher-level functional capacity of an older population living in a Japanese urban community","volume":"36","author":"Fujiwara","year":"2003","journal-title":"Arch Gerontol Geriatr"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"136","DOI":"10.2188\/jea.JE20210077","article-title":"Relationship of higher-level functional capacity with long-term mortality in Japanese older people: NIPPON DATA90","volume":"33","author":"Nagata","year":"2023","journal-title":"J Epidemiol"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"211","DOI":"10.1093\/gerona\/gly024","article-title":"Association of trajectories of higher-level functional capacity with mortality and medical and long-term care costs among community-dwelling older Japanese","volume":"74","author":"Taniguchi","year":"2019","journal-title":"J Gerontol A Biol Sci Med Sci"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"105096","DOI":"10.1016\/j.archger.2023.105096","article-title":"Impact of combinations of subscale declines in higher-level functional capacity on 8-year all-cause mortality among community-dwelling older Japanese adults","volume":"114","author":"Kawai","year":"2023","journal-title":"Arch Gerontol Geriatr"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"137","DOI":"10.1007\/s40520-024-02791-x","article-title":"Aging trajectories of subscales in higher-level functional capacity among community-dwelling older Japanese adults: the Otassha study","volume":"36","author":"Kawai","year":"2024","journal-title":"Aging Clin Exp Res"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"501","DOI":"10.11236\/jph.56.8_501","article-title":"Examination of risk factors for onset of certification of long-term care insurance in community-dwelling older people: AGES project 3-year follow-up study","volume":"56","author":"Hirai","year":"2009","journal-title":"Nihon Koshu Eisei Zasshi"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"312","DOI":"10.1159\/000354962","article-title":"Cognitive decline predicts long-term care insurance requirement certification in community-dwelling older Japanese adults: a prospective cohort study","volume":"3","author":"Nishiguchi","year":"2013","journal-title":"Dement Geriatr Cogn Dis Extra"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"79","DOI":"10.1111\/j.1741-6612.2012.00601.x","article-title":"Predictors of eligibility for long-term care funding for older people in Japan","volume":"32","author":"Moriya","year":"2013","journal-title":"Australas J Ageing"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"170","DOI":"10.3143\/geriatrics.51.170","article-title":"Evaluation of multimodal factors for the certification of long-term care insurance among community-dwelling elderly: a four-year follow-up study","volume":"51","author":"Konagaya","year":"2014","journal-title":"Nihon Ronen Igakkai Zasshi"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"246","DOI":"10.11236\/jph.64.5_246","article-title":"Development of risk assessment scales for needed support\/long-term care certification: a longitudinal study using the Kihon checklist and medical assessment data","volume":"64","author":"Tsuji","year":"2017","journal-title":"Nihon Koshu Eisei Zasshi"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"601","DOI":"10.1161\/CIRCULATIONAHA.115.017719","article-title":"Introduction to the analysis of survival data in the presence of competing risks","volume":"133","author":"Austin","year":"2016","journal-title":"Circulation"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"4391","DOI":"10.1002\/sim.7501","article-title":"Practical recommendations for reporting Fine-Gray model analyses for competing risk data","volume":"36","author":"Austin","year":"2017","journal-title":"Stat Med"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"496","DOI":"10.1080\/01621459.1999.10474144","article-title":"A proportional hazards model for the subdistribution of a competing risk","volume":"94","author":"Fine","year":"1999","journal-title":"J Am Stat Assoc"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"174","DOI":"10.4235\/agmr.20.0037","article-title":"Long-term care system in Japan","volume":"24","author":"Yamada","year":"2020","journal-title":"Ann Geriatr Med Res"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"522","DOI":"10.1111\/j.1532-5415.2005.53175.x","article-title":"Care-needs certification in the long-term care insurance system of Japan","volume":"53","author":"Tsutsui","year":"2005","journal-title":"J Am Geriatr Soc"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1298\/ptr.R0013","article-title":"An overview of social participation in older adults: concepts and assessments","volume":"24","author":"Hashidate","year":"2021","journal-title":"Phys Ther Res"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"467","DOI":"10.1093\/gerona\/glq231","article-title":"Relation of late-life social activity with incident disability among community-dwelling older adults","volume":"66","author":"James","year":"2011","journal-title":"J Gerontol A Biol Sci Med Sci"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"1003.e7","DOI":"10.1016\/j.jamda.2015.08.023","article-title":"Social frailty in community-dwelling older adults as a risk factor for disability","volume":"16","author":"Makizako","year":"2015","journal-title":"J Am Med Dir Assoc"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"456","DOI":"10.2188\/jea.JE20200574","article-title":"Association between social participation and disability-free life expectancy in Japanese older people: the Ohsaki cohort 2006 study","volume":"32","author":"Matsuyama","year":"2022","journal-title":"J Epidemiol"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"e99638","DOI":"10.1371\/journal.pone.0099638","article-title":"Social participation and the prevention of functional disability in older Japanese: the JAGES cohort study","volume":"9","author":"Kanamori","year":"2014","journal-title":"PLoS One"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1016\/j.jpsychores.2018.05.004","article-title":"Association between social participation and incident risk of functional disability in elderly Japanese: the Ohsaki cohort 2006","volume":"111","author":"Otsuka","year":"2018","journal-title":"J Psychosom Res"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"1881","DOI":"10.1111\/jgs.18269","article-title":"Social participation and incident disability and mortality among frail older adults: a JAGES longitudinal study","volume":"71","author":"Abe","year":"2023","journal-title":"J Am Geriatr Soc"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"e030500","DOI":"10.1136\/bmjopen-2019-030500","article-title":"Social participation and the combination of future needs for long-term care and mortality among older Japanese people: a prospective cohort study from the Aichi gerontological evaluation study (AGES)","volume":"9","author":"Takahashi","year":"2019","journal-title":"BMJ Open"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"799","DOI":"10.1093\/geronb\/gbw059","article-title":"Social participation and cognitive decline among community-dwelling older adults: a community-based longitudinal study","volume":"73","author":"Tomioka","year":"2018","journal-title":"J Gerontol B Psychol Sci Soc Sci"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"545","DOI":"10.2188\/jea.JE20190337","article-title":"Cultural engagement and incidence of cognitive impairment: a 6-year longitudinal follow-up of the Japan gerontological evaluation study (JAGES)","volume":"31","author":"Sugita","year":"2021","journal-title":"J Epidemiol"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"105944","DOI":"10.1016\/j.archger.2025.105944","article-title":"Comparing the incidence rates of dementia: association of social participation among older adults in Japan","volume":"137","author":"Fujihara","year":"2025","journal-title":"Arch Gerontol Geriatr"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"886","DOI":"10.1097\/EDE.0000000000001395","article-title":"Estimating the impact of sustained social participation on depressive symptoms in older adults","volume":"32","author":"Shiba","year":"2021","journal-title":"Epidemiology"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"1095","DOI":"10.1111\/psyg.13163","article-title":"Association between the level of social participation and depressive symptoms among older Japanese adults: a cross-sectional survey","volume":"24","author":"Shimoda","year":"2024","journal-title":"Psychogeriatrics"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1950765\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T04:26:00Z","timestamp":1791260760000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1950765\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,6]]},"references-count":40,"alternative-id":["10.3389\/fpubh.2026.1950765"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1950765","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,6]]},"article-number":"1950765"}}