Original Article

Global Health & Medicine. 2024; 6(1):70-76.
DOI: 10.35772/ghm.2023.01072

Factors associated with community residents' preference for living
at home at the end of life: The Yamagata Cohort Survey
Tomoko Saito1,*, Tsuneo Konta2, Sachiko Kudo1, Yoshiyuki Ueno3
1

Department of Nursing, Yamagata University School of Medicine Hospital, Yamagata, Japan;
Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan;
3
Department of Gastroenterology, Yamagata University School of Medicine, Yamagata, Japan.
2

Abstract: Japan's rapidly aging and high-mortality society necessitates a wider awareness and implementation ofadvance care planning. This Yamagata Cohort study investigated local residents' preferences for where they would
like to spend their final days, and the underlying factors associated with those preferences with a self-administeredquestionnaire survey of local residents aged 40 years and over . Logistic regression analyses were used to assess
those factors and, specifically, the choice of "Home" as the preferred place for end-of-life residence. Among the
10,119 responders, 61% chose their home as the most desirable place to spend their final days. The multiple logistic
regression analysis showed that the independent factors associated with the choice of "Home" were: male, older age,not living with someone who needs care, not discussing the end of life, currently happy, struggling to live on current
income, not feeling anxious or depressed, and current place of residence the same as their grandparents' birthplace.
This suggested that reducing the burden of home care and addressing frequent emotional issues such as happiness andanxiety could increase the number of people choosing "Home". Open-ended comments indicated the importance ofgetting information and options, and discussing the choice of place for terminal care in light of individual backgrounds
including having reservations about family. Support and systems are needed to understand what community residents
consider important when deciding where to spend their final days, and to bridge the gap between their desired locationand their actual end of life.
Keywords: final days, advanced care planning, terminal care, life choices

Introduction

surveys exist on this topic. Yamagata Prefecture hassome of the highest aging and mortality rates in Japan;
33.8% of its population is 65 years or older, the mortality
rate is 503.1 per 100,000, and the death rate from senility
is 202.3 per 100,000 (the highest in Japan). Importantly,
the death rate at home is only 14.4% (6), which is lower
than the national average. The purpose of this study was
to clarify the prevalence of local Yamagata residents
who preferred their own home as the place in which they
wished to receive terminal care, to explore the factors
related to and the thoughts behind this preference, and to
examine the issues involved in realizing people's wishes
for their terminal care in a comprehensive community
system.

As the demand for end-of-life care increases with theprogression of an aging and high-mortality society inJapan, so does the need for advance care planning (ACP).
ACP is a process in which the patient, their family, andtheir medical care team discuss in advance the medicalcare that the elderly patient desires and will receive intheir final stage of life (1). Surveys of the general public
and local residents have reported that one's own home
is the most popular place to spend one's final days, with36.6% to 60.0% choosing this option (2-5); however,
only 17.2% of deaths actually occur at home (6).
Furthermore, the desired place to receive terminal carevaries widely depending on the presence or absence ofterminal cancer, cardiac disease, or dementia, as well as
the stage of the patient's illness (1).
Several studies have shown that the factors related
to the individual attributes of those who prefer theirown home as the place to receive end-of-life care and to
spend their final days are male, elderly, and living witha caregiver or children (2-4); however, few detailed

Materials and Methods
Study participants and survey procedures
The Yamagata Cohort Study was supported by the 21stCentury COE Program and the Global COE Program andwas conducted in seven cities in Yamagata Prefecture(70)

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from 2009 to 2015. Participants were local residents
covered by the National Health Insurance system; mostwere engaged in agriculture, forestry, and fishery, wereself-employed, part-time workers, retired workers, or
unemployed. In the present study, health and lifestylequestionnaires were mailed from December 2021 toMarch 2022 to 17,527 of the 20,969 baseline participants(i.e., those who responded to the original survey)
who were known to be alive in December 2021. The
questionnaires were returned by 12,216 respondents(response rate 69.7%), and analysis was conducted on
the 10,119 who provided valid responses regarding theplace in which they prefer to receive end-of-life care.

Declaration of Helsinki and was approved by the Ethics
Committee of Yamagata University School of Medicine(2009–1222, 2022–193).
Results
Overview of participants and their preferences for where
to receive their end-of-life care
The number of valid responses to the self-administeredquestionnaire was 10,119, of which 4,072 (40.2%) weremale and 6,047 (59.7%) were female. The mean age was
71.9 ± 8.0 years; 1,649 (16.3%) were between 40 and 64
years old, 4,315 (42.6%) were 65–74 years old (i.e., early
elderly), and 4,155 (41.0%) were 75 years old or more
(i.e., late elderly).
The most common preference for where to spend
one's final days was "Home" (6,184 participants,
61.1%). "Not Home" was 3,935 (38.8%), which included
Hospitals (2,028, 19.2%), Nursing homes (1,818,
17.2%), and "Other" places (89, 0.84%). A total of 3,549
respondents (35.0%) reported that they discuss or havediscussed end-of-life care with their families (Table 1).
We compared the characteristics of participants whochose "Home" as their desired place to spend their final
days with "Not Home". Those who chose "Home" weremore likely to be male (Home 45.1% vs. Not Home
32.5%), late elderly (Home 44.1% vs. Not Home 36.1%),
had not discussed their end of life (Home 33.8% vs. Not
Home 37.0%), were not living with someone who neededcare (Home 7.8% vs. Not Home 9.8%), currently happy(Home 87.6% vs. Not Home 84.1%), not feeling anxious
or depression (Home 26.7% vs. Not Home 31.8%), andliving in a place of residence that was the same as their
grandparents' birthplace (Home 46.4% vs. Not Home
39.6%).

Survey items
The questionnaire comprised items that covered thefollowing topics: sex, age, whether they discussed endof-life issues (Yes/No), whether they live with someone
who needs care (Yes/No), whether they have a family
doctor (Yes/No), whether they consult with family andfriends (Yes/No), their current level of happiness (Happy/
Neutral/Unhappy), their living situation on their current
income (Comfortable/Neutral/Suffering), Whether they
feel forgetful (Yes/No), whether they feel anxious or
depressed (Yes/No), whether their current residence
and their grandparents' birthplace are the same (Same/
Not same), and what their preferences were for where
they would like to spend the final days of their life bychoosing "Home" or "Hospital/Nursing home/Other".
Regarding where they would like to spend the final daysof their life, "Hospital/Nursing home/Other" was definedas "Not Home", and comparisons were made between"Home" and "Not Home". In addition, an open-ended
item was included in "Other".
Statistical analysis

Factors associated with the choice of "Home" as thepreferred place in which to spend one's final days

A t-test and a chi-square test were conducted to compare
continuous and categorical parameters between those
who answered "Home" and "Not Home" as theirpreferred place to receive terminal care. Simple andmultiple logistic regression analyses were conducted
to identify factors independently associated with those
whose preference was "Home". Open-ended items werequalitatively categorized and simply tabulated. A p-valueof less than 0.05 was considered statistically significant.
Statistical software JMP pro16 for Windows was used
for all statistical analyses.

We conducted simple and multiple logistic regression
analyses on the factors associated with the answer,"Home", in response to the item, "place I want to spend
my final days". In the simple logistic regression analysis,
the associated factors were: male, late elderly, having
end-of-life discussions, living with someone who needscare, being happy, not feeling anxious or depressed andthe same current place of residence as the grandparents'
birthplace (Table 2). In the multiple logistic regression
analysis, the independently associated factors were: male(odds ratio [OR]: 1.59, 95% confidence interval [CI]:1.45–1.74), late elderly (OR: 1.63, 95% CI: 1.43–1.85),
not having end-of-life discussions (OR: 1.17, 95% CI:
1.07–1.28), not living with someone who needs care
(OR: 1.18, 95% CI: 1.02–1.37), currently being happy(OR: 1.35, 95% CI: 1.18–1.55), having a difficult living
situation on current income (OR: 1.16, 95% CI: 1.05–

Ethical considerations
When the questionnaires were distributed, an overview ofthe study, including the voluntary nature of participationand the protection of personal information, was provided
to the participants, and consent was obtained in writing.
This study was conducted in accordance with the(71)Global Health & Medicine. 2024; 6(1):70-76.

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Table 1. Participants' characteristics
Characteristics
Sex
Male
FemaleAge group
40–64 years old
65–74 years old (Early elderly)
75 years old or more (Late elderly)
Having end-of-life discussions
Yes
Have a family doctor
Yes
Living with someone who needs care
Yes
Consultation with family or friends
Yes
Current level of happiness
NeutralHappy
Unhappy
Living situation on current income
NeutralComfortable
Suffering
Forgetfulness
Yes
Anxiety or depression
Yes
Place of residence and grandparents' birthplace
Same

Total
10,119 (100%)

Home
6,184 (61.1%)

Not Home
3,935 (38.8%)

4,072 (40.2%)
6,047 (59.7%)

2,793 (45.1%)
3,391 (54.8%)

1,279 (32.5%)
2,656 (67.5%)< 0.001

1,649 (16.3%)
4,315 (42.6%)
4,155 (41.0%)859 (13.8%)
2,592 (42.6%)
2,733 (44.1%)

790 (20.0%)
1,723 (43.7%)
1,422 (36.1%)< 0.0013,549 (35.0%)

2,090 (33.8%)

1,459 (37.0%)< 0.001

9,164 (90.5%)

5,607 (90.6%)

3,557 (90.3%)

0.643

872 (8.6%)486 (7.8%)

386 (9.8%)< 0.001

8,296 (83.6)

5,076 (83.7%)

3,220 (83.4%)

0.715

1,117 (11.2%)
8,577 (86.2%)
247 (2.4%)

626 (10.3%)
5,325 (87.6%)
125 (2.0%)491 (12.7%)
3,252 (84.1%)
122 (3.1%)< 0.001

5,801 (58.9%)
1,046 (10.6%)
2,994 (30.4%)

3,541 (58.9%)606 (10.0%)
1,865 (31.0%)

2,260 (59.0%)440 (11.4%)
1,129 (29.4%)

0.045

7,890 (78.8%)

4,799 (78.4%)

3,091 (79.4%)

0.218

2,840 (28.7%)

1,615 (26.7%)

1,225 (31.8%)< 0.001

4,399 (43.8%)

2,848 (46.4%)

1,551 (39.6%)< 0.001

p-value

Table 2. Factors associated with the desire to spend one's final days at Home
Factors
Sex
Male (vs. Female)Age group
40–64 years
65–74 years old (Early elderly)
75 years old or more (Late elderly)
Having end-of-life discussions
No (vs. Yes)
Have a family doctor
No (vs. Yes)
Living with someone who needs care
No (vs. Yes)
Consultation with family or friends
Yes (vs. No)
Current level of happiness
NeutralHappy
Unhappy
Living situation on current income
NeutralComfortable
Suffering
Forgetfulness
No (vs. Yes)
Anxiety or depression
No (vs. Yes)
Place of residence and grandparents' birthplace
Same (vs. Not same)

SimpleOR (95% CI)

p-value

MultipleOR (95% CI)

p-value

1.71 (1.57–1.86)< 0.001

1.59 (1.45–1.74)< 0.0011
1.38 (1.23–1.55)
1.77 (1.57–1.98)< 0.001< 0.0011
1.32 (1.17–1.74)
1.63 (1.43–1.85)< 0.001< 0.001

1.15 (1.06–1.25)< 0.001

1.17 (1.07–1.28)< 0.001

0.97 (0.84–1.11)

0.644

1.10 (0.96–1.28)

0.177

1.28 (1.11–1.47)< 0.001

1.18 (1.02–1.37)

0.030

1.02 (0.92–1.14)

0.715

1.05 (0.93–1.18)

0.409

1
1.28 (1.13–1.46)
0.80 (0.61–1.06)< 0.0010.121

11.35 (1.18–1.55)
0.86 (0.65–1.16)< 0.0010.326

10.88 (0.77–1.00)
1.05 (0.96–1.15)

0.059
0.253

1
0.90 (0.78–1.03)
1.16 (1.05–1.28)

0.141
0.003

1.06 (0.96–1.17)

0.218

1.06 (0.95–1.18)

0.280

1.28 (1.17–1.40)< 0.001

1.15 (1.05–1.27)

0.004

1.32 (1.22–1.43)< 0.001

1.23 (1.13–1.34)< 0.001(72)

Global Health & Medicine. 2024; 6(1):70-76.

www.globalhealthmedicine.com1.28), not feeling anxious or depressed (OR: 1.15, 95%
CI: 1.05–1.27), and the same current place of residence
as the grandparents' birthplace (OR: 1.23, 95% CI: 1.13–
1.34) (Table 2).

1.55–2.50), being currently happy (OR: 1.40, 95% CI:
1.02–1.93), not having end-of-life discussions (OR: 1.32,
95% CI: 1.04–1.66), and suffering in living situation
on current income (OR: 1.30, 95% CI: 1.04–1.63). In
the 65–74-year-old (early elderly) group, the extracted
five factors were: male (OR: 1.65, 95% CI: 1.44–1.90),
being currently happy (OR: 1.31, 95% CI: 1.05–1.62),
not having end-of-life discussions (OR: 1.21, 95%
CI: 1.06–1.39), not feeling anxious or depressed (OR:1.21, 95% CI: 1.04–1.41), and having the same current
place of residence as the grandparents' birthplace (OR:
1.16, 95% CI: 1.03–1.33). In the 75 years and older(late elderly) age group, four associated factors wereextracted: male (OR: 1.42, 95% CI: 1.24–1.63), being
currently happy (OR: 1.39, 95% CI: 1.12–1.74), having
the same current place of residence as the grandparents'
birthplace (OR: 1.32, 95% CI: 1.15–1.52), and not
feeling anxious or depressed (OR: 1.17, 95% CI:
1.00–1.37). The analysis clearly showed that the factors
most commonly associated with "Home" as the "place I
want to spend my final days" for all ages were male andbeing currently happy (Supplemental Table S2, https://www.globalhealthmedicine.com/site/supplementaldata.
html?ID=73).

Subgroup analyses by sex and age
Since gender and age were strongly related to the
choice of "Home" in the multivariate analysis of Table
2, we conducted subgroup analyses by gender and age
considering the possibility that factors related to the
choice of "Home" differ by gender and age. A total of
10,119 patients were included in the subgroup analysis.
In the "sex" subgroup analysis, the associated factors formen were, in descending order of OR: being currently
happy (OR: 1.56, 95% CI: 1.27–1.91), having the same
current place of residence as the grandparents' birthplace(OR: 1.21, 95% CI: 1.05–1.39), and suffering in thecurrent living conditions (OR: 1.17, 95% CI: 1.00–
1.37). For women, the nine associated factors were, indescending order of OR: being late elderly (OR: 1.84,
95% CI: 1.57–2.15), being early elderly (OR: 1.39, 95%
CI: 1.20–1.60), not living with someone who needs care
(OR: 1.36, 95% CI: 1.13–1.64), having the same current
place of residence as the grandparents' birthplace (OR:1.24, 95% CI: 1.11–1.39), not having a family doctor(OR: 1.22, 95% CI: 1.02–1.46), being currently happy(OR: 1.21, 95% CI: 1.01–1.46), not having end-of-life
discussions (OR: 1.21, 95% CI: 1.08–1.35), not feelinganxious or depressed (OR: 1.16, 95% CI: 1.03–1.31), andsuffering in living situation on current income (OR: 1.16,
95% CI: 1.02–1.31). Thus, the factors associated with
"Home" as the "place I want to spend my final days"
differed by sex, with females having more facilitating
factors than males (Supplemental Table S1, https://www.globalhealthmedicine.com/site/supplementaldata.
html?ID=73).
In the "age" subgroup analysis, the significantly
associated factors in the 40–64-year-old group were,in descending order of OR: male (OR: 1.97, 95% CI:

Open-ended responses to the question, "Where do you
want to spend your final days?"
Of those who answered "Other" to the question about
where they would like to spend their final days, 306
provided qualitative responses in the open-ended items.
The answers were categorized by descriptive similarities,
as follows: "Don't know/can't decide/thinking aboutit", "Specific place (e.g., fee-based senior citizen home,
hospice, or child's home) ", "Depends on the physicalcondition and situation at the time", "Does not think
about it or does not want to think about it", "Abides by
the family's wishes or a place that does not disturb thefamily and surroundings", and "No preference/anywhereis fine" (Figure 1). Actual examples of "Don't know/can't

Figure 1. Open-ended response to the question, "Where do you want to spend your final days?"(73)

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decide/thinking about it" statements were: "I don't know
because I have never thought about it", and "My spouseis dead and I am an elderly person living alone so I
have no one to consult". A further example of "Depends
on the physical condition and situation at the time"statement was, "Hospital if I am sick, nursing home if I
have dementia, home if I am well". Another example of"Abides by the family's wishes or a place that does not
disturb the family and surroundings" was, "Anywherethat will not inconvenience my family". A further
example of "Specific place" was, "A nursing home that is
adequate for my income".

their final days at home is a natural extension of theirpresent life. It is also possible, however, that participants
are optimistic about the possibility of spending their final
days at home as an extension of their current life because
they are unable to visualize information and options
such as illness and nursing care. Further investigationis needed to determine the relationship between sudden
physical deterioration owing to aging and the availabilityof information about situations requiring nursing care.
Difficulty living on current income
Sugimoto et al. suggest that economic level can leadto decision-making that is contrary to the will of theindividual and their family members (7); those inlower economic brackets have fewer opportunities
and less capacity to care for their elderly than thosein higher economic brackets, and thus may initiate
home care for unavoidable reasons and are less likely
to express a preference for spending their final days athome. Furthermore, Noguchi reports that the elderlywith dementia may not be able to choose the place oftreatment for their terminal care owing to the limitationsof family caregiving and economic hierarchy that cannot
afford the cost of institutionalization (8).
As the present super-aging society emerges in Japan,
people's economic situations and their family's lack of
caregiving capacity may prevent them from choosing
nursing homes or long-term care facilities, and they
may be forced to choose their own home. We believethat social support policies and the provision of easily
accessible information are necessary to enable people tochoose the medical treatment they desire at the end of
their lives.

Discussion
Factors associated with "Home" as the "place where I
want to spend my final days"
In this study, several factors associated with "Home"as the preferred place to receive end-of-life care wereconsistent with previous studies (2,3): male, not livingwith a person in need of care, early elderly, and lateelderly. Importantly, new associated factors were also
found: not having end-of-life discussions, being currently
happy, difficulty living on one's current income, notfeeling anxious or depressed, and the current place ofresidence being the same as the grandparents' birthplace.
Furthermore, subgroup analyses showed that theassociated factors differed by sex and age: females had
more multiple associated factors, and all age groups wereassociated with the common factors.
Not having end-of-life discussions
In this study, 61.1% of the respondents who preferred"Home" as the place in which to receive end-of-lifecare reported not discussing where they would spend
their final days. Inagaki et al., by contrast, reported nodifference between holding end-of-life discussions andthe preferred place for end-of-life care (2). One possible
reason for this is that a low percentage of the participantsin the present study had discussed end-of-life care, and
it is possible that they did not have a concrete imageof what their end-of-life care would be or of the place
where they would spend their final days. However,
the open-ended answers suggest that perhaps theseparticipants wished to stay at home but were hesitant totell their families about their wishes because they did notwant to bother their families or were simply unsure, andas a result, they did not discuss end-of-life care with theirfamilies.

Current place of residence is the same as the grandparents'
birthplace
Although this study did not investigate the rate of
cohabitation, 43.8% of respondents were born —and continue to live — in the same place as their
grandparents, which may indicate that they are familiar
with and attached to the community and their home. In
the Nippon Foundation's survey report (4), respondents
gave reasons for choosing their current home, such as "Ifeel safe and the surroundings are familiar" and "I can bemyself until the end of my life". The survey also foundthat for local residents, those who continue to live in theplace where they were born and raised are more likely
to want to stay at home. Furthermore, the participantsin the present study were agricultural, forestry, fisheries
or self-employed workers, this may have contributed totheir desire to stay in the familiar surroundings of theirhometowns or homes until the end of their lives.

Being happy and not feeling anxious or depressed
No previous study has examined the association between
being happy and not feeling anxious or depressed, andthe preferred place for spending one's final days. Our
results suggest that for a person who is currently happy
at home and has no anxiety, the idea of wanting to spend

What local residents consider important when thinking
about the place to receive their end-of-life care
Although 95.8% of participants in this study indicated a(74)

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specific preference for where they wanted to spend their
final days, only 35.0% had actually discussed end-of-lifecare with their families. In addition to the main category,"Don't know/can't decide/thinking about it", the themesthat were extracted from the open-ended responses
indicate a wide variety among local residents in theirconsiderations of where to spend their final days andreceive terminal care, which depends on their individual
circumstances and associated choices (e.g., "follow
family's wishes, a place that will not bother family or
surroundings" and "depends on physical condition andcircumstances at the time"). This outcome may be anindication of the difficulty that Japanese people tend to
experience in being both reserved and assertive toward
their families and others.
The category, "follow the family's wishes and do notwant to inconvenience the family and surroundings" hasalso been mentioned in previous surveys as a factor thatis taken into consideration when thinking about terminal
care (1,9). The results of a Nippon Foundation survey(4), however, show a discrepancy between parents' andchildren's end-of-life medical care and recuperationpreferences and their thoughts about those choices:parents do not want to "burden the family" at the end of
their life, but children may not know this reality and want
their parents "to receive aggressive medical treatment"and "to live as long as possible". For this reason, we
believe it is important for families to discuss not only thephysical location of the place where the person wants tospend their final days, but also the thoughts behind theperson's wishes.
Many participants also indicated that their choiceof location for spending their final days and receiving
terminal care "depend[s] on the physical conditionand circumstances at the time of death". The Japanese
Ministry of Health, Labour and Welfare promotes theestablishment of a comprehensive regional support andservice delivery system to enable the elderly to continue
to live their lives in their familiar neighborhoods
for as long as possible. The objective is to preserve
people's dignity, support independent living, andprovide palliative care and end-of-life care at homeregardless of disease or physical condition, as well as
the enhancement of services to reduce the burden ofcare on families. However, available resources andmaintenance conditions vary from region to region (10)and the options are likely to be narrowed dependingon factors such as economic level (7) and the presenceor absence of dementia (8). Public health approaches
to end-of-life care have the potential to enhance theintegration of services and provide a comprehensive
approach that engages the assets of local communities(11). Therefore, when discussing places for end-oflife care, it is important for local residents to haveknowledge and information about the actual medical
and nursing care options available in their area forterminal physical and mental health conditions.

Towards a community where people can choose "Home"as the place where they spend their final days
Surveys of the preferences of the general public andterminally ill people report a growing consensus that,with sufficient support, most people would prefer toreceive end of life care at home (12). Table 2 showsthat among the factors related to not choosing to stayat home, the items that can be improved include:
avoiding having a person in need of care at home,increasing the number of people who feel happy in theircurrent situation and increasing the number of people
who are not anxious/unhappy. Each of these is foundwith frequency in having a person in need of care athome (8.6% of all respondents), not feeling happy inthe current situation (Unhappy 2.4%, Normal 11.2%)
and being anxious/depression (28.7%). In particular,
addressing the more frequent, mental health issues suchas happiness and anxiety could significantly increase
the number of people choosing "Home" as the place
where they spend their final days.
Conversely, this is might also true for those whochoose "Home" as a place to spend their final days,
who are satisfied with their current living environment,
have less anxiety and fear about the end of life andimage of death, and have a more positive view of death.
Maintaining health and well-being may lead to betterend of life care (13), and creating a community wheremore people choose "Home" may help to create a society
where residents are healthy in mind and body, benefit
from a comprehensive community system and live ahappier life now.
Strengths and limitations of this study
The strengths of this study include the large sample
size (the largest among past surveys in Japan) and thelarge geographical area from which responses wereobtained within the prefecture. These factors facilitate
an understanding of the preferences and thoughts of awide range of local residents regarding places in which
to receive end-of-life care. Several limitations should
be noted. First, there may have been selection bias. The
participants in this study regularly receive community
health checkups, have a high level of health awareness,
and are currently in good health; therefore, they may
not have information on or specific images of end-oflife medical care or be aware of the options available tothem for places of recuperation. Second, this survey was
conducted only once. Participants' opinions may change
depending on their physical condition and surrounding
circumstances.
Conclusion
This study identified factors associated with community
residents' desire to spend their final days at home.

(75)

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When considering where community residents should
spend their final days, it is necessary to understand theirpersonal characteristics and what is important to them,and to provide support and systems that can bridge thegap between their desired location and their actual end of
life.

6.

Funding: The Yamagata Cohort Study is supported by
the 21st Century COE Program and the Global COE
Program.

8.

7.

9.

Conflict of Interest: The authors have no conflicts ofinterest to disclose.
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dl/saisyuiryo_a_h29.pdf (accessed April 28, 2023). (inJapanese)
Inagaki A, Takano J, Noguchi M, Yamamoto N:
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---Received July 2, 2023; Revised September 30, 2023; Accepted
October 26, 2023.
Released online in J-STAGE as advance publication November
2, 2023.
*Address correspondence to:
Tomoko Saito, Department of Nursing, Yamagata University
School of Medicine Hospital, 2-2-2 Iida-Nishi, Yamagata 9909585, Japan.
E-mail: tomomasahome1@yahoo.co.jp(76)