Volume 2│Number 1

February 2023

Journal of International Nursing Research
Editor-in-Chief
Naohiro Hohashi, PhD, RN, PHN, FAAN
Graduate School of Health Sciences, Kobe University, Japan

Deputy Editor
Chia-Chin Lin, PhD, RN, FAAN
School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR

Editorial Advisor
Kiyoko Fukai, PhD, RN, PHN
Graduate School of Nursing, The Jikei University, Japan

Associate Editors
Mikako Arakida, PhD, RN, PHN

Polly Siu Ling Chan, RN, BHSc, MPHC, DHSc

Justina Yat-Wa Liu, RN, PhD

Kawasaki City College of Nursing,Japan

School of Nursing, Li Ka Shing Faculty of
Medicine, The University of Hong Kong,
Hong Kong SAR

School of Nursing, Hong Kong Polytechnic University, Hong Kong SAR

Yasuko Shimizu, PhD, RN, PHN

Mayuko Tsujimura, PhD, RN, PHN

Yoshie Yokoyama, PhD, RN, PHN

Graduate School of Medicine, Osaka
University, Japan

School of Nursing, Shiga University of
Medical Science, Japan

Graduate School of Nursing, Osaka City
University, Japan

Naoki Yoshinaga, PhD, RN, CPP, MSN

Shawn Yong-Shian Goh, BHSN, MN, PhD

Kieko Iida, PhD, RN, PHN

School of Nursing, Faculty of Medicine,
University of Miyazaki, Japan

National University of Singapore, Singapore

Graduate School of Nursing, Chiba University, Japan

Publication information: The Journal of International Nursing Research (JINR) is an English-language publication launchedin 2022. It is the international journal of the Japan Society of Nursing Research (JSNR), the oldest and most prestigious nursing society in Japan, which was founded in 1975. For more information, please refer to the following website: https://www.jsnr.
or.jp/english/
Manuscripts: Visit https://www.jinr.jsnr.or.jp/. If you encounter any problems with online submission, please contact the Editorial Office, at jinr@kyorin.co.jp.

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Online ISSN: 2436-1348
Print ISSN: 2436-3448
Copyright © 2023 by the Japan Society of Nursing Research (JSNR). All rights reserved. No portionof the contents may be reproduced in any form without written permission from the publisher.
Printed in Japan

Journal of International Nursing Research
Volume 2

Number 1

February 2023

Volume 2 Number 1 February 2023

Contents
Editorial
Journal of International Nursing Research forges ahead!

e2023-0001

Naohiro Hohashi, PhD, RN, PHN, FAAN

Review Article
End-of-life care in intensive care units: A concept analysis

e2022-0001

Yuri Sakaki, MSN, RN, and Misuzu Nakamura, PhD, RN

Use of comprehensive home care assessment tools for communitydwellingolder adults to improve adherence, quality of life, and health outcomes:
A systematic review and meta-analysis

e2021-0018

Tomoko Kamei, RN, PHN, PhD, Sachie Eto, RN, PHN, PhD, Aki Kawada, RN, PHN, MSN,
Yoko Takahata, RN, PHN, PhD, Akiko Sasaki, RN, PHN, PhD, Yoko Uchida, R.N, PhD,
Yukiko Fukuta, RN, PHN, MS, Sugako Kurimori, PhD, Kosuke Kimura, RN, PHN, MS,
and Setsu Shimanouchi, RN, PHN, PhD

Original ResearchPhysiological and psychological effectiveness of facial massage in women:
A randomized crossover trial

e2021-0005

Yuriko Ohkawa, MSN, Hiroki Tanoue, PhD, and Kiyoko Fukai, PhD

Pro ciency evaluation of simulation education on the entire tracheal
suctioning process using a motion capture system and a catheter control
sensing device

e2021-0016

Noriyo Colley, EdD, RN, Shunsuke Komizunai, PhD, Satoshi Kanai, PhD, Atsushi Konno, PhD,
Sozo Inoue, PhD, Misuzu Nakamura, PhD, RN, and Shinji Ninomiya, PhD

Effects of footbaths on prefrontal cortex activity and autonomic nervous function:
A randomized controlled crossover trial

e2021-0027

Kosuke Maeda, PhD, Takako Ohba, MNS, Tomofumi Kato, MNS, and Akihiro Shuda, PhD

Collaborative visits by hospital specialist nurses with homecare nurses:
A nationwide, cross-sectional, web-based survey

e2021-0011

Aruha Masuda, MHS, RN, PHN, Mariko Sakka, PhD, RN, Satomi Kitamura, PhD, RN,
Ayumi Igarashi, PhD, RN, Maiko Noguchi-Watanabe, PhD, RN, Akiko Araki, DNSc, RN,
and Noriko Yamamoto-Mitani, PhD, RN

Development of a reliable and valid cancer-related communication scalefor use between breast cancer survivors and their adolescent children

e2021-0009

Rei Oshiro, PhD, RN, Masahiko Tanabe, PhD, MD, Keiichiro Tada, PhD, MD, Junko Takei, MD,
Hideko Yamauchi, MD, and Kiyoko Kamibeppu, PhD, RN, FAAN

Mental health status of public health nurses and its related factors under
the coronavirus disease 2019 pandemic in Japan
Karen Tsuruda, MSN, and Yoko Hatono, PhD

e2022-0007

Factors interfering with behavioral change in patients with non-alcoholic
fatty liver disease: An ethnographic studye2021-0032

Takahiro Kawabata, RN, MSN, Michiko Moriyama, RN, MSN, Ph.D, Mayumi Niitani, RN, MSN, Ph.D,
and Basilua Andre Muzembo, MD, PhD

Brief Report
Effectiveness of a cervical cancer prevention program to improve healthliteracy among Japanese undergraduate females in their 20s:
A quasi-experimental studye2021-0029

Shiho Kawata, PhD, RN, PHN, and Emiko Saito, PhD, RN, PHN

Possibilities and challenges of dialogic approach training forchild guidance center staff

e2021-0030

Akiko Kadoma, PhD, RN, PHN, Mami Yamamoto, PhD, RN, PHN, Midori Asano, PhD, RN, PHN,
Koji Shiraki, Clin. Psy., Rikuya Hosokawa, PhD, RN, PHN, Hirofumi Sato, PhD, MD,
Hitomi Nakahata, MN, RN, PHN, and Mari Kato, MN, RN, PHN

Erratum
Erratum for DOI: 10.53044/jinr.2021-0014
Naoki Kuramoto, MSN, RN, and Yoriko Watanabe, PhD, RN

e2022-err001

https://doi.org/10.53044/jinr.2023-0001
https://www.jinr.jsnr.or.jp/

Editorial

Journal of International Nursing Research forges ahead!
Naohiro Hohashi, PhD, RN, PHN, FAAN1, 2
Editor-in-Chief, Journal of International Nursing Research, and 2Graduate School of Health
Sciences, Kobe University, Kobe, Japan1

It is with great pleasure that we present our second issue of Journal of International Nursing Research (JINR) while at the sametime acknowledging the support of The Japan Society of Nursing Research (JSNR), which oversees publication of JINR.
By the end of 2022, JINR had received more than 50 original submissions per year from around the world. We would like toexpress our thanks to the authors who have chosen JINR for their submissions, the Editorial Committee and our hardworking
reviewers. When the number of papers submitted to JINR has increased sufficiently and JINR has securely established itself as
an international journal, we will give consideration to publishing more than one issue per year.
Like most new publications, JINR faces a number of challenges, and we are making strong efforts to confront them. The Editorial Committee is constantly discussing the review process and taking steps to improve it, such as by gradually reducing theturn-around time for conducting reviews. In particular, the Editorial Committee continues to encourage submissions fromresearchers around the world and has been redoubling its efforts to facilitate recruitment of knowledgeable reviewers.
New from 2022 was our launch of awards to recognize excellence in the work our reviewers have been performing. These“Outstanding Reviewer Awards” accord recognition to the achievements by high-quality reviewers of the submissions to JINR,
so as to promote the development of new research in the field. JINR evaluates the peer reviews submitted during each fiscal year,
and from these selects up to five deserving reviewers who have demonstrated exceptional excellence in their work. It is hopedthat more individuals will agree to undertake reviews for JINR so as to make themselves eligible for Outstanding Reviewer
Awards.
Since 2020, we believe that new, cutting-edge nursing research and practice have been conducted in a variety of areas related
to the novel coronavirus pandemic that has ravaged humanity. JINR welcomes a wide variety of submissions on this and othertopics that relate to nursing science, in the form of review articles, original research, practice guidelines, technical reports andbrief reports. We deeply desire to have JINR contribute to the further development of nursing science, and to this end, encourage
you to share your research results with our readers, so as to expand the circle of research and practice. For further information
including guidelines for submission, please visit the JINR web site at https://www.jinr.jsnr.or.jp/.
JINR 2023, 2 (1), e2023-0001

Correspondence: N. Hohashi. Email: naohiro@hohashi.org
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 1https://doi.org/10.53044/jinr.2022-0001
https://www.jinr.jsnr.or.jp/

Review Article

End-of-life care in intensive care units: A concept analysis
Yuri Sakaki, MSN, RN1 , and Misuzu Nakamura, PhD, RN2
1

Doctor’s Program in Nursing, The Jikei University Graduate School of Medicine, Tokyo, Japan, and 2Graduate
School of Nursing, The Jikei University School of Medicine, Tokyo, Japan

AbstractEnd-of-life care should be considered a part of the nursing profession, specifically in intensive care units [ICUs].
Although various definitions of end-of-life care have been proposed by nursing academies and associations, aclear definition of end-of-life care in ICUs is yet to be determined. Thus, in this concept analysis, we aim to define
end-of-life care in the ICU. In this study, we utilized Walker and Avant’s concept analysis method, which is designed to identify the structure and definition of a concept like end-of-life care in ICU. In this concept analysis, twoantecedents, four attributes, and three consequences of end-of-life care in ICU were extracted, and its definition
was thereafter clarified. These results are highly useful and can support critical care nurses, as they are the ones
who provide optimal care for dying patients and their families in the ICU; they also form a basis for further research with regard to end-of-life care in the field of critical care nursing. The prominent features of end-of-life carein ICU are as follows: a high dependency on medical equipment, short-term care, and focus on care for families
as most patients are unconscious. These features reflect the definition of end-of-life care in ICU. End-of-life care in
ICU were defined as intensive and short-term care for patients who are facing imminent death and their families,
to help them live out their lives with dignity.
Keywords
end-of-life care, intensive care units, concept analysis, critical care nursing
JINR 2023, 2(1), e2022-0001

BackgroundNursing deals with individuals’ health at all developmental
stages and all points in the health-illness continuum. Thus,
end-of-life care should be considered as part of the profession. As nurses assist people in health and recovery, as well
as for dying with dignity (International Council of Nurses,
2002), end-of-life care is a significant subject that must be
discussed in the field of nursing. Additionally, because nursing care is provided to people at any level of health, end-oflife care is necessary in the critical care provided in intensive care units [ICUs].
ICUs are staffed by specially trained medical personnel

and equipped for continuous monitoring and life support.
Their primary purpose is to ensure the survival of patients ina life-threatening state of health (Kelly et al., 2014). Thus,
at the beginning of ICU history, end-of-life care might not
be included in the primary purpose of the establishment of
ICUs. However, death can occur in ICUs for many reasons.
Therefore, the need for end-of-life care in ICUs is deemed
understandable.
The concept of end-of-life care―including the terms “terminal care” and “palliative care” for patients with cancer orindividuals who are HIV-positive―was first defined in the
1990s (Radbruch, 2020). As population aging has seen asteady increase worldwide, the concept has spread to geron-

Correspondence: Y. Sakaki. Email: nd2002sakaki@jikei.ac.jp
Received: January 6, 2022, Accepted: June 1, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 9JINR 2023, 2(1), e2022-0001

People begin
to becomeaware ofdeath

https://doi.org/10.53044/jinr.2022-0001

Declaring one’s
own death,
discussing itwith family andhealth careproviders

A state ofaffairs
between lifeand death

Usual span of time

In ICUs

Figure 1. Scope of end-of-life care in this study.

tology care, meaning good death or death with dignity. Several organizations have proposed definitions of end-of-lifecare. For example, the National Health Service (2018) statesthat “end of life care is support for people who are in thelast months or years of their life.” At the National Cancer
Institute (2021), end-of-life care is defined as “care given to
people who are near the end of life and have stopped treatment to cure or control their disease.” Given the primary
purpose of ICUs, the end-of-life care in ICUs might include
different aspects from general definitions and might be more
intensive and provided in a short period of time (shown in
Figure 1). Thus, there is a need to clarify the definition of
end-of-life care in ICUs.

Objective
In this concept analysis, we aimed to determine the definition of end-of-life care in ICUs. A better understanding of
this concept may support critical care nurses in providing
optimal care for dying patients, and their families, in ICUs,
thus contributing to further research related to end-of-lifecare.

Methods
Concept Analysis Model
Concept analysis refers to “the process of inquiry that explores concepts for their level of development or maturity as
revealed by their internal structure, use, representativeness,
and/or relations to other concepts” (Morse et al., 1996). In
nursing, the foremost concept analysis models are often derived from Wilsonian methods, which include the methodsof Walker and Avant (2019). Walker and Avant’s methods
are known to focus on examining the structures and functions of a concept and identifying it clearly (Walker &2 of 9Avant, 2019).
This analysis adopts Walker and Avant’s method as it intends to identify the structure and definition of a concept
such as end-of-life care in the ICU and further examine endof-life care in critical care nursing, following their steps ofanalysis;
1. Select a concept.
2. Determine the aims or purposes of analysis.
3. Identify all uses of the concept that you can discover.
4. Determine the defining attributes.
5. Identify a model case.
6. Identify borderline, related, contrary, invented (not always), and illegitimate cases (not always).
7. Identify antecedents and consequences.
8. Define empirical referents.
(Walker & Avant, 2019).
Although this study discusses the steps in the concept
analysis as if they were sequential, they are often iterative(Walker & Avant, 2019). The iterative nature of the process
enables accurate and precise analysis of a concept.
Data Collection
A literature review was conducted using several databases
across disciplines, and a physical search in printed dictionaries and books was also performed. Some older classicaltexts and literatures were included in the physical search.
Other than that, all searches included studies from the past
10 years, and only full texts were extracted, as per the inclusion criteria.
PubMed was used to find studies with the keywords “endof-life care” NOT “nursing” to avoid selecting nursing literatures and to select only medical literatures. Scopus was
also searched to find sociological and psychological studies,as it is known to have a rich literature in sociology and psychology. The keywords “end-of-life care” AND “sociology,”https://doi.org/10.53044/jinr.2022-0001

and “end-of-life care” AND “psychology” were used. As per
the exclusion criteria, non-English literatures, other focus(i.e., unrelated to nursing) were excluded.
A more detailed literature search was conducted for nursing. The term “end-of-life” is often discussed in oncology,
gerontology, and critical care (Saga et al., 2018). Pediatricend-of-life care also requires interventions, and research inthese fields requires for improved interventions (Weaver etal., 2019).
PubMed was used to search keywords “end-of-life care”
AND “pediatrics” or “end-of-life care” AND “children,” forpediatric nursing. The key phrase “concept analysis” wasadded to these. For oncology nursing, PubMed was used tosearch the keywords “end-of-life care” AND “cancer” or“end-of-life care” AND “oncology.” In gerontology nursing,
the keywords searched for were “end-of-life care” AND“elderly” or “end-of-life care” AND “dementia.” For criticalcare nursing, the keywords were “end-of-life care” AND“ICU,” or “end-of-life care” AND “critical care,” or “endof-life care” AND “emergency,” and the keyword “concept
analysis” was added.

Results
Definitions of the Concept of End-of-life Care
Dictionaries and Academic Associations or Professional Organizations
The general dictionary defines end-of-life care as healthcare
for people with terminal conditions or in the last days andhours of their lives. End-of-life care also includes palliative
care (Macmillan Dictionary, 2021). Although the World
Health Organization (2021) does not define end-of-life care,palliative care is defined as “an approach that improves thequality of life of patients and their families facing problems
associated with life-threatening illness, through the prevention and relief of suffering by means of early identificationand impeccable assessment and treatment of pain and otherproblems, physical, psychosocial, and spiritual” (p.25). The
National Health Service (2018) in the United Kingdom
states that “end of life care is support for people who are in
the last months or years of their life.” At the National Cancer Institute (2021) in the United States, end-of-life care has
been defined as “care given to people who are near the endof life and have stopped treatment to cure or control theirdisease.” End-of-life care may include palliative care, supportive care, and hospice care. In medical dictionary, end-oflife care is defined as “multidimensional and multidisciplinary physical, emotional, and spiritual care of patient withterminal illness, including support for family and caregivers”(Medical Dictionary, 2021).
There are some differences between these definitions, interms of time and period, ranging between the last months
or years and the last days and hours. Many definitions do

JINR 2023, 2(1), e2022-0001

not describe a length of time at all.
Related Disciplines
Medicine
In total, we found 11,428 papers in the field of medicine,
based on the criteria of our literature review. We sorted
these using the keyword “concept analysis,” and 132 papers
remained. Some of these papers were found to be related totreatment, such as chemotherapy or sedation, at the end-oflife (Muishout et al., 2018; Somashekhar et al., 2018). Endof-life symptom management is also an important concern
in medicine (Khosravani et al., 2020; Mohamed et al.,2016). Informed consent plays a key role for physicians;
moreover, communication with patients and their families isthe primary interest of some physicians and certain studies(Masel et al., 2016; Muramoto, 2016). Several papers describe law and ethics for end-of-life care (Derse et al.,2019), and Mohamed et al. (2016) argue that it is importantto take a multidisciplinary approach.
Considering these, in the discipline of medicine, the main
themes regarding end-of-life care were treatment and symptom management, communication with patients, law andethics, and multidisciplinary approach.
Sociology
In total, 14 papers from sociology were selected based on
our search criteria. One study describes the professional andorganizational logistics for the delivery of end-of-life careand how finance is part of it (Bailey et al., 2020). Anotherfocuses on socially vulnerable populations, such as the poorand the homeless (Stajduhar et al., 2019), highlighting thenecessity of providing knowledge for service providers andpolicymakers to remove socioeconomic barriers for equitable
end-of-life care for all populations. Some studies also state
the importance of cultural beliefs in end-of-life care (Gysels
et al., 2011; Inbadas, 2017).
The extracted works show that the issue of financial andsocial problems such as poverty and the importance of cultural beliefs are delineated.
Psychology
In addition to the criteria described above, the keyword“concept” was added to psychology, and 31 papers were
thereafter selected. Similar to sociology, papers discussing
culture were found (Strautmann et al., 2020). There werealso articles on people suffering from dementia and theirfamilies (Krawczyk & Gallagher, 2016; Kupeli et al., 2019).
Research on religion or spiritual care regarding end-of-life isa feature of the field of psychology (Choudry et al., 2018;
Okamura et al., 2018). In one study, it was found that carehomes and hospitals for older adults should consider obtaining more religious resources as support for staff and patients(Okamura et al., 2018). Spiritual care was found to be afundamental consideration in addressing the holistic experiences of patients receiving palliative care (Choudry et al.,2018).
3 of 9JINR 2023, 2(1), e2022-0001

Attributes of End-of-life Care in ICUs
Discipline of Nursing
Several nursing academies and associations have discussed
and educated nurses in regard to end-of-life care. The Endof-Life Nursing Education Consortium (ELNEC) is one suchproject (End-of-Life Nursing Education Consortium, 2020).
According to Ferrell et al. (2015), ELNEC explains that“palliative care nursing reflects a “whole person” philosophyof care implemented across the life span and across diverse
healthcare settings. The patient and family is the unit ofcare. The goal of palliative nursing is to promote quality oflife along the illness trajectory through the relief of suffering, and this includes care of the dying and bereavement
follow-up for the family and significant others in the patient’s life.” Another organization that focuses on end-of-life
care, the Royal College of Nursing (2020), states that “endof-life care is not just the practical and technical delivery ofcare provided to the individual who is dying, but also refers
to the support and information available both to them andthe people who are important to them, e.g., bereavement
support.”In nursing, we conducted a more detailed literature searchand selected 43 papers from oncology, 68 papers from gerontology, 20 from pediatric, and 49 from critical care nursing.
In critical care nursing, communication with paramedical
staff, patients, and families is deemed important (Ecarnot etal., 2018). Chuang et al. (2017) state that communication
with terminally ill patients and their families is also forphysicians’ assistants. Regarding brain death, Muramoto(2016) discusses the difficulties in obtaining informed consent from families. In the field of pediatric nursing, interviews with mothers show the importance of communication
between providers and parents about end-of-life care for
their child (Neglia et al., 2013).
In end-of-life care, surrogates’ decision-making has been
identified to be crucial. Discussing end-of-life care preferences early in the treatment could potentially enhance surrogates’ end-of-life decision-making processes (Daneau et al.,2020). Aizawa et al. (2013) address the decision-making
process for end-of-life care and withholding or discontinuing
life-prolonging treatments. Furthermore, to make ethicallysound do-not-resuscitate [DNR] decisions, physicians andnurses need to develop appropriate virtues and improve theirknowledge on ethical theories and relevant clinical guidelines (Pettersson et al., 2018). Decision-making, especiallysurrogate decision-making by families or relatives, is the key
to end-of-life care.
According to Muishout et al. (2018), applying palliative
sedation is one of the primary issues in end-of-life care in
relation to patients’ religious and cultural backgrounds.
Amblàs-Novellas et al. (2016) list symptoms that should be
4 of 9https://doi.org/10.53044/jinr.2022-0001

managed in the early stages of end-of-life care, including
functional and nutritional progression and emotional distress.
Alsuwaigh (2015) states that “personhood is temporally
and contextually sensitive, allowing for better appreciationof the evolving goals of care that frequently occur at end-oflife. Most importantly, this study reminds healthcare professionals on the importance of “treating persons,” and looking
beyond familial interests in maintaining the interests anddignity of the patient.” Dignity is essential for the conceptof end-of-life care, for older adults and for any person who
are nearing their end-of-life.
Considering end-of-life preferences of patients with a migration history (Paal & Bükki, 2017), the suppression of
end-of-life discussions was associated with suffering andloss of autonomy among migrants. Muishout et al. (2018)
describe Muslim norms concerning palliative sedation.
Simha et al. (2013) conducted a research on spiritual concerns among people of the Hindu religion undergoing palliative care. Respect for the cultural background of patients isimportant in the concept of end-of-life care.
Critical Care Nursing
Good communication, supportive decision-making, symptom
management, multidisciplinary approach, dignity, and respect for cultural backgrounds are identified as important attributes to the concept of end-of-life care. These are common in not only critical care nursing, but also in pediatric,
oncology, and gerontology nursing.
Discussions on withholding and withdrawal in the context
of end-of-life care often occur in ICUs, with patients being
provided with advanced medical equipment such as ventilators (Aizawa et al., 2013). Once advanced and intensive interventions have started, the DNR directive is always a dilemma among healthcare providers (Paal & Bükki, 2017). A
high dependency on medical equipment is one of the key
features of end-of-life care in ICUs. This means that criticalcare nurses are required to assess competencies for analyzing information from medical equipment.
Another feature of end-of-life care in ICUs is the shorttime period. Compared to other nursing fields, critical carenursing comprises of short-term care. Lunney et al. (2003)
have categorized the differences in the trajectories of dying
into showing sudden death, terminal illness, organ failure,and frailty, and critical care nursing is related to all thesefour trajectories. The one in which death is rapidly imminent in hours to days is probably the most relevant to critical care nursing. Often, both the patient and their family are
unprepared to face the rapid deterioration of their condition.
This is another feature of end-of-life care in ICUs.
Most patients in the ICU do not have the ability to makedecisions, due to being sedated, or, otherwise, unconscious.
For example, Muramoto (2016) describes the difficulties related to informed consent before brain death is diagnosed.
The debates around the withdrawal of life support and organhttps://doi.org/10.53044/jinr.2022-0001

donation make it even more complicated. In these cases,
families or relatives suffer the distress of surrogate decisionmaking even if patients have living will. Diminished orcomplete lack of the ability of decision-making in patientsthemselves and the need to focus on the family and surrogate decision-making are other features of end-of-life care in
ICUs.
Symptom management is a common feature of end-of-lifecare in any nursing field. In critical care nursing, patients
often experience various symptoms, such as dyspnea, pain,and distress, and these would require strong sedative medication. Appropriate assessment of the effects of medications
and the management of physical symptoms with dignity are
deemed important.
Therefore, it can be concluded that surrogate decisionmaking support for families, management of physical symptoms with dignity, intensive and short-term care in a state ofunpreparedness, and assessment of information from medical
devices the patient is highly dependent on for life support
are the attributes of end-of-life care in the ICU.
Antecedents and Consequences of the Concept of End-of-life
Care in ICUs
In the ICU, there are often few viable treatments available,
after the application of many medical devices and several interventions. Additionally, death is imminent for patients whoare in an end-of-life state. These are the antecedents of theconcept of end-of-life care in ICUs.
The bereavement experience, adaptation, and continuationof bonds and memories are often consequences of a good
death (Broden et al., 2020). Furthermore, meeting the needsof family members has been identified as one of the highest
priorities while caring for dying patients. Based on interviews with ICU nurses about end-of-life decision-making,
Baliza et al. (2015) have stated the importance of patients
working and communicating with their families to deal with
end-of-life situations.
These studies suggest that the family’s situation is key toits consequences. The family’s sense of nurses attending to
the patient/family and communication between medical staff
and patients/family members can be observed in the ICU.
Adaptation and memories that are seen as a long-term normal grief process may not be observed in the ICU, eventhough these are important. ICU nurses can only ensure thatfamily members feel that their loved one has lived their life
to the fullest. The factors of good communication with families and medical staff, the family’s sense that nurses are always with them, and their feeling that the patient has lived
their life to the fullest are suggested as consequences of theconcept of end-of-life care in ICUs.
The antecedents, attributes, and consequences derived
from our concept analysis are shown in Figure 2.

JINR 2023, 2(1), e2022-0001

Example Cases of End-of-life Care in ICU
Next, we will show a model case, borderline case, relatedcase, and contrary case each, in an attempt to explain theconcept of end-of-life care in ICUs.
Model Case
Construction of cases from everyday experiences that bestreflect or illustrate the concept.
Ms. A, a 55-year-old female with cardiac pulmonary arrest, was transported to the emergency room. She was stillin a deep coma after the return of spontaneous circulation
and was medically diagnosed with a subarachnoid hemorrhage. The attending physician informed Ms. A’s older sisterthat she has a life-threatening condition and no treatment
was available. She was disturbed and crying. A nurse suggested she should call other family members. An hour later,
Ms. A’s younger sister arrived at the hospital, also crying.
The nurse was with the sisters, to respond any questions
they may have. The younger one pleaded with the physician
to do everything possible. However, the older sister stated
Ms. A’s wish for a peaceful death under life-threatening conditions. There is no living will of Ms. A. The nurse thenasked if that is what Ms. A always thought. The sisters said
how gentle and considerate the nurse was, which reminded
them of Ms. A’s wish for a gentle and peaceful death. Finally, the sisters decided not to resuscitate her. Ms. A was ahigh school teacher, and the nurse encouraged her sisters toshow her pictures of Ms. A’s students, as she loved themdearly. Three days later, Ms. A’s heart rate declined gradually, and she passed away. The sisters were still crying, butthey thanked the medical staff and left the hospital. After 1
month, they came to the hospital and said, “Thank you foryour encouragement at that time. We are still grieving, but
we have started a new life and spend every day with Ms.
A’s memories.”
Borderline Case
A case that may possibly be an instance of the concept, but
the analyst is unsure; some of the features may be present,
but other important features may be missing.
Mr. B, a 42-year-old male, with convulsions arrived at thehospital by ambulance. Administration of anticonvulsantscaused his convulsions to diminish. His wife arrived and revealed a history of metastatic brain tumor. Due to the anticonvulsants, Mr. B’s condition stabilized, and he was transferred from the ICU to a general ward. Mr. B understoodthat he had a life expectancy of approximately 1 year. Two
weeks after being admitted, the patient was unable to walkand eat. Mr. B and his wife were eager to go home before
his life ended. They discussed discharge plans with the physician and nurses and informed them of their wish to go
back to their home. One week later, Mr. B passed away athome, surrounded by his family.
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https://doi.org/10.53044/jinr.2022-0001

Antecedents

・Few viable
treatments areavailable・Death of patients isimminent

Attributes

・Surrogate decisionmaking support forfamilies

Consequences

・Good communication
with families andmedical staff

・Management of physicalsymptoms with dignity
・Intensive and short-termcare in a state ofunpreparedness
・Assessment of・Family senses that
nurses are always withthem・Family’s feeling thatpatient has lived theirlife to the fullest

information from medical
devices patient is highly
dependent on for life
supportFigure 2. Concept of end-of-life care in ICU.

Related Case
A case illustrating instances related or connected to the concept in an important way.
Mr. C is an 80-year-old male with a history of lung cancer; he was admitted to the hospital with dyspnea and severe
back pain. He was diagnosed with lung cancer and a metastatic lumbar tumor. Mr. C required bed rest and positionchanges; however, when nurses tried to change his position,
he complained of back pain. The nurses wanted to alleviate
his pain and distress and asked a physician to consult an anesthesiologist with a pain control specialty. Narcotic painkillers were thereafter prescribed to Mr. C whose back pain
was alleviated and complaints diminished.
Contrary Case
A case or instance that does not reflect the concept.
Ms. D is an 80-year-old female with a history of chronic
obstructive pulmonary disease who used home oxygen therapy. She complained of dyspnea and loss of consciousness
at home. She decided not to use the ventilator at the outpatient clinic, and her doctor understood and adhered to her
wishes. However, Ms. D’s daughter became very upset andcalled the emergency department. The attending physician in
the emergency room asked the daughter if she wanted them
6 of 9to intubate and use a ventilator. The daughter, who was still
upset, answered affirmatively. After arriving at the emergency room, Ms. D’s daughter, who had calmed down,thought that she had perhaps made the wrong choice. She
asked the ER physician whether she should use the ventilator. The physician answered, “You wanted to use it. Once apatient has come to the ER, we do our best to save theirlife.” Ms. D was intubated and placed on a ventilator.
Definition
The definition of end-of-life care in ICUs is as follows: Intensive and short-term care for patients who are facing imminent death, and their families, to help them live out theirlives with dignity. It is a nursing practice in which nurses
focus on being with, and supporting, the patient and theirfamily. Nurses aim to manage painful symptoms and support
the surrogate decision-making of families, while accurately
assessing the patient’s physical functions, to ultimately enable the patient to live their life to the fullest, and the family
to feel as such.

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JINR 2023, 2(1), e2022-0001

Discussion

Conclusion

We extracted four attributes of the concept of end-of-lifecare in ICUs. Alftberg et al. (2018) describe communication
about death and dying with older people in nursing homes
as an important consideration in palliative care. This is oneof the core attributes, not only for older people in nursing
homes, but also for younger people in ICUs. In some cases,
ICU patients are in a coma, with their families present.
Decision-making issues were shown as another attribute of
end-of-life care. Pettersson et al. (2018) state that nurses andphysicians need to improve their knowledge of ethical theories and the relevant guidelines regarding DNR decisions inoncology care. This attribute is common to oncology andcritical care. Likewise, dignity and symptom management
are important in all fields of nursing. In ICUs, the distressrelated to medical devices, in addition to other physicalsymptoms such as dyspnea or pain, is noted to be high.
Therefore, the management of patients’ physical symptoms
with dignity is an important attribute of end-of-life care in
ICUs.
The prominent features of critical care regarding end-oflife care are discussed next. For one, Aizawa et al. (2013)
discuss the withholding and withdrawal of end-of-life treatment. The termination of advanced treatments or interventions such as a ventilator or continuous hemodiafiltration always include an ethical dilemma. A high dependency on
medical equipment is a prominent feature of end-of-life carein ICUs. ICU nurses need to assess information from these
medical devices, in addition to physically assessing the patient.
Unlike gerontology or oncology nursing, short-term careis another feature of end-of-life care in critical care. In
many cases, ICU nurses often start end-of-life care for patients whom they have met for the first time. Additionally,in the ICU, it is not unusual for patients to be unconscious;
therefore, end-of-life care tends to focus on families.
The consequences of end-of-life care are good communication with families and medical staff, the sense that nurses
are always with them, and the feeling that patients have
lived their lives to the fullest. In critical care, consequences
are more focused on the families, compared to other fields
of nursing. This is because, for some patients, the physicalconditions are usually too severe to consider them. The family’s feeling that nurses are with them and that the patient
has lived their life to the fullest can be observed during thepatient’s stay in the ICU. Family members’ normal griefprocess is an important consequence of end-of-life care in
ICUs; however, it may not be observed in the ICU after thepatient’s discharge. Suggestions of bereavement care for thefamily may be helpful. Follow-up care may be needed in the
future as a continuing care for families of patients passed
away while in ICU.

In this concept analysis of end-of-life care in ICUs, two antecedents are extracted as follows:(1) Few viable treatments are available.
(2) Death of patients is imminent.
Furthermore, four attributes are indicated as follows:(1) Surrogate decision-making support for families(2) Management of physical symptoms with dignity(3) Intensive and short-term care in a state of unpreparedness(4) Assessment of information from patients highly dependent on medical devices for life support
Lastly, the consequences of the concept of end-of-life carein ICUs are as follows:(1) Good communication with families and medical staff(2) Family’s sense that nurses are always with them(3) Family’s feeling that patient has lived their life to thefullestThese results are highly useful, and may support criticalcare nurses in providing optimal care for dying patients andtheir families in the ICU, and contribute to conducting further research related to end-of-life in the field of criticalcare nursing.
Acknowledgments
We would like to thank Editage (www.editage.com) for English language editing.
Author Contributions
Yuri Sakaki was involved in the concept or design of thework, literature search, data analysis and interpretation,
drafted the manuscript, and revised it critically for important
intellectual content. Misuzu Nakamura was also involved in
the concept or design of the work, data analysis and interpretation, and has critically revised the draft for important
intellectual content.
Declaration of Conflicting Interests
The authors declare no conflict of interest.
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Review Article

Use of comprehensive home care assessment tools for communitydwelling older adults to improve adherence, quality of life, and healthoutcomes: A systematic review and meta-analysis
Tomoko Kamei, RN, PHN, PhD1 , Sachie Eto, RN, PHN, PhD1 , Aki Kawada, RN, PHN, MSN1 ,Yoko Takahata, RN, PHN, PhD2 , Akiko Sasaki, RN, PHN, PhD3 , Yoko Uchida, R.N, PhD4 ,Yukiko Fukuta, RN, PHN, MS5 , Sugako Kurimori, PhD6 , Kosuke Kimura, RN, PHN, MS7 , andSetsu Shimanouchi, RN, PHN, PhD8
1

Graduate School of Nursing Science, St. Luke’s International University, Tokyo, Japan, 2School of Nursing, Tokyo
Women’s Medical University, Tokyo, Japan, 3Faculty of Medical Science and Welfare, Tohoku Bunka Gakuen
University, Sendai, Japan, 4Graduate School of Health Sciences, Gunma University, Mebashi, Japan, 5School of
Nursing, Sugiyama Jogakuen University, Nagoya, Japan, 6Department of Nursing, Seitoku University, Matsudo,
Japan, 7Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan, and 8Japan
Education/Research Center for Home Care, Tokyo, Japan

Abstract
Comprehensive homecare assessment has been determined to be essential in the context of care management
for community-dwelling older adults. However, the effectiveness of assessment tools for adherence and health outcomes is yet to be fully elucidated. Thus, in this systematic review, we aim to evaluate the effects of comprehensive homecare assessment tools on adherence and other health outcomes among community-dwelling older
adults. Database searches were performed using CINAHL Plus with full text, PubMed, EMBASE, CENTRAL, andIchushi. Randomized controlled trials search were conducted until September 2020. Studies comparing interventions using comprehensive homecare assessment tools were assessed using the Cochrane’s risk of bias 2 forquality; in randomized trials, a meta-analysis was performed. Nine articles, including eight studies, were includedin this review. All interventions involved comprehensive homecare assessment tools such as CGA, SEISAR, RAIHC, TARGET combined with interRAI-HC, MDS-HC, and the Omaha system. As per the results of the metaanalysis, no difference was observed with regard to adherence (p =.11), hospital admission (p =.29), nursing
home admission (p =.70), and mortality (p =.96) compared with the non-use of the assessment tools. The mental
quality of life showed a significant effect in the comprehensive assessment group (standardized mean difference =0.26; 95% confidence interval = 0.06 to 0.46; p =.01); however, certainty of the evidence (GRADE) was assessed
to be moderate. Comprehensive homecare assessment tools may be particularly useful for enhancing the psychological quality of life beyond a comprehensive assessment. This review presents insufficient evidence to support
adherence to homecare and the enhancement of other health outcomes for community-dwelling older adults.
Keywords
adherence, homecare assessment tool, meta-analysis, quality of life, systematic review
JINR 2023, 2(1), e2021-0018

Correspondence: T. Kamei. Email: kamei@slcn.ac.jp
Received: September 14, 2021, Accepted: July 1, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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Introduction
Homecare demand and the use of health services have seena recent increase in our super-aged society (Humphries,
Thorlby, Holder, Hall, & Charles, 2016; MHLW, 2020).
Thus, a standardized homecare assessment in primary caresettings has been an urgent requirement to extensively
screen and assess people at home (Chi, Chou, Kwan, Lam,
& Lam, 2006). A previous study suggested that a proactive,
integrated care provision for older adults in the community
is needed to address complex care needs, enhance independent living, and improve quality of life (QOL) (Rechel,
Grundy, Robine, Cylus, Mackenbach, Knai, & McKee,2013). A complete in-home assessment of patients as well as
informal caregivers has been considered indispensable for
identifying specific care needs, coordinating care demands,
and appropriate care planning (Fabacher, Josephson,
Pietruszka, Linderborn, Morley, & Rubenstein, 1994). Comprehensive multidimensional assessment tools for older
adults include the assessment of physical function and psychological state, as well as family caregivers and home environment (Rubenstein, Siu, & Wieland, 1989; Fabacher et al.,
1994; Morris et al., 2009; Landi et al., 2000; Japan Visiting
Nursing Foundation, 2001; Weatherall, Slow, & Wiltshire,
2004; O’Connor, & Davitt, 2012; Røsstad, Garåsen, Steinsbekk, Sletvold, & Grimsmo, 2013; Røsstad, Salvesen,
Steinsbekk, Grimsmo, Sletvold, & Garåsen, 2017; Wagner,
Schaffert, Möckli, Zúñiga, & Dratva, 2020). Moreover, it
has been suggested that multiple follow-up home visits canbe beneficial in preventing nursing home admissions andfunctional decline in older adults (Stuck, Egger, Hammer,
Minder, & Beck, 2002).
The original purpose of homecare assessment was to obtain extensive information regarding a person so that caremanagers and healthcare providers could provide appropriate
care (Wieland & Hirth, 2003). In the late 1980s and theearly 2000s, several standardized tools and instruments forhomecare assessment have been developed to specifically
improve the quality of homecare for older adults. These include the Comprehensive Geriatric Assessment (CGA)(Rubenstein et al., 1989); the Minimum Dataset for Homecare (MDS-HC) (Morris et al., 2009); the Japanese Assessment and Care Plan for Long-Term Care (Jac-LTC) (Japan
Visiting Nursing Foundation, 2001), the Outcome and Assessment Information Set (OASIS) (O’Connor, & Davitt,2012); the Omaha system (Martin, 2005); and the Resident
Assessment Instrument for Home Care (RAI-HC) (Wagner
et al., 2020). These tools and instruments contain items essential for identifying a patient’s community care service
needs and quantifying the need for a healthcare reimbursement level (Davitt & Kaye, 2010). Consequently, the National Institute for Health Care Excellence suggested the“social care quality-adjusted life year” (NICE, 2014), which
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has been defined to focus on homecare for older adults,
placing more emphasis on QOL rather than physical health.
Assessment Tool Use in Homecare Management and QOL
Improvement
Homecare is a type of care delivery characterized by providing interdisciplinary visits to clients at home. In Japan, thenumber of homecare services has increased fourfold over the
past two decades, representing 77.6% of long-term care insurance care deliveries (MHLW, 2020). Under Japan’s longterm care insurance system, the first general assessment tool
is used to designate the client’s care level. Thereafter, caremanagers perform more comprehensive assessments to makeappropriate care plans.
Concerning older adults, age-related frailty and illness arecommonly affected by environmental and lifestyle factors(Ye, Gao, & Fu, 2018). Therefore, functional assessments ofolder adults are required to determine not only their physicalcare needs but also their psychosocial and lifestyle careneeds, as well as their need for QOL. An assessment allows
healthcare providers to deliver person-centered care (Wiltjer& Kendall, 2019). Homecare assessment is often performed
through professional clinical interviews with the patient andfamily caregivers with regard to anxiety, depressive symptoms, and observations about activities of daily living,
physical function, social relations, and caregiver situation.
Recently, several reports suggested that assessment toolbased interventions have the potential to improve health outcomes (Rubenstein et al., 1994; Bruce et al., 2007; Rubenstein, Stuck, Siu, & Wieland., 1991; Suijker, Rijn, Buurman,
Ter Riet, Moll van Charante, & Rooij, 2016). Although previous studies have already explored the effectiveness ofthese tools, adherence and QOL are yet to be adequately
discussed.
Thus, in this systematic review and meta-analysis, weaimed to evaluate the effectiveness of a comprehensive assessment tool used to assess intervention adherence and improve health outcomes and QOL of older adults receiving
homecare.

MethodIn this systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) statement (Moher et al., 2015). The Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
checklist is presented in Supplementary Table 1. The protocol was registered in the International Prospective Register
for Systematic Reviews (PROSPERO) (CRD42021238737)
from the National Institute for Health Research.
Published Work Search Strategies and Sources
We performed a comprehensive literature search of the pub-https://doi.org/10.53044/jinr.2021-0018

lished work. The search dates of the databases were not limited. The databases used in this study were the CumulativeIndex of Nursing and Allied Health Literature (CINAHL)
Plus full text database (including PsycINFO and MEDLINE)
through the EBSCOhost interface, PubMed, EMBASE, Cochrane CENTRAL Register of Controlled Trials (CENTRAL), and Ichushi-Web, a Japanese literature database. All
the databases, keywords, and combinations used in thissearch are listed in Supplementary Table 2. The search for
published work was conducted in September 2020. Published conference proceedings, including abstracts, were also
reviewed. Gray literature, such as unpublished articles or articles that were not easily accessible via databases, were excluded. A manual search was not performed.
Study Selection and Data Extraction Process
The suitability of each study was assessed in three steps:
First, two of the ten authors and four collaborator dyads independently reviewed the abstracts, screened, and applied
selection criteria to identify suitable studies. In this screening process, we used a web app for systematic reviews
called Rayyan software (Ouzzani, Hammady, Federowicz, &Elmagarmid, 2016). Second, two author/collaborator dyads
independently reviewed the full text of the articles for eligibility. Third, each article was analyzed using the Cochrane
Data Extraction and Assessment Template. The suitability ofthe selected studies for review and meta-analysis was discussed by the entire research team, and any disagreements
were resolved via consensus.
The inclusion criteria were as follows: (i) original andpeer-reviewed studies written in English or Japanese; (ii)studies using a comprehensive assessment tool for assessing
homecare recipients; (iii) studies that reported the development of a care plan by nurses or other healthcare providers,
depending on the assessment; and (iv) studies that utilized
any type of randomized controlled trial (RCT), such as individual, cluster, quasi, and crossover design RCTs. In thisstudy, an assessment tool was defined as a comprehensive
dataset that covered the physical, psychological, and social
aspects of homecare recipients.
The exclusion criteria were as follows: (i) qualitative, observational, and quasi-experimental studies; (ii) pre- andpost-tests without comparators; (iii) prospective cohort studies; (iv) case studies; (v) studies describing preventive inhome assessments; and (vi) studies with an incomprehensive
assessment such as activities of daily living (ADL) and/or
instrumental ADL (IADL), which do not provide an organized assessment. If an article did not provide the mean andstandard deviation (SD) of the continuous data of the outcomes, we asked the authors via email if they could provide
them for the meta-analysis.

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Quality Assessment
Two author dyads independently assessed the risk of bias of
the included RCTs. The Cochrane’s risk of bias 2 (ROB2)
for randomized trials (Sterne et al., 2019) was used for thescreening. The assessed domains were the randomization
process, deviation from interventions, missing outcome data,
outcome measurement, and selection of the reported result.
Reporting bias was assessed using funnel plots (Higgins &Thomas, 2021). The certainty of the evidence was assessedusing GRADEpro software (McMaster University and Evidence Prime Inc., 2021).
Outcomes
We included articles in the meta-analysis if they reported theoutcome measures of the following parameters: primary outcome, namely, the number of participants who did not withdraw homecare during the follow-up period (adherence), andsecondary outcomes, namely, ADL, QOL, emergency department visits, hospital, and nursing home admission, and mortality.
Statistical Analysis
A meta-analysis was performed using the Review Manager
5.4.3 software (the Nordic Cochrane Center, Copenhagen).
Data were thereafter synthesized into forest plots, and arandom-effects model was used to analyze the intervention
effects across all studies. The risk ratio (RR) was determined for outcome measures of dichotomous variables,
whereas the mean difference (MD) or standard mean difference (SMD) was calculated for continuous data. To confirm
the reliability of the summary estimates, 95% confidence intervals (CIs) were calculated. The variables in each study
were distilled from the data to facilitate intention-to-treat
analysis of the original group. We recorded missing data anddropout rates for each RCT and reported the number of participants included in the meta-analysis as the reported number in the study. An estimate of the intracluster correlation
coefficient was calculated if the data from a cluster-RCT
study were synthesized for meta-analysis and adjusted tocorrect for the design effect for meta-analysis (Higgins &Thomas, 2021). Sensitivity analyses were performed to assess the stability of the meta-analysis results. Subgroup
analysis was performed for groups of studies using the assessment tool. Statistical heterogeneity was analyzed using
the I2 statistic, and I2 !60% was considered to indicate significant heterogeneity. A random-effects model was used in
the meta-analysis.

Results
Flow of Study Selection
In total, 2,113 studies were identified during the database
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Additional records identified
through other sources(n = 0)Records identified throughdatabase search(n = 2,113)
PubMed
CINAHLCENTRAL
EmbaseIchushi

737
730
159
310
177

Records after duplicates (259) removed(n = 1,854)

Records screened(n = 42)

Full-text articles assessed
for eligibility(n = 8)(9 studies)

Records excluded(n = 1,812)
Wrong drug (n = 1,252)Wrong study (n = 952)
Background article (n = 511)
Wrong population (n = 322)
Wrong publication type (n = 19)
Wrong study duration (n = 8)
Foreign language (n = 7)
Wrong outcome (n = 3)
(Multiple selection)

Full-text articles excluded(n = 33)
Wrong intervention (n = 18)
Wrong participants (n = 8)
Not RCT (n = 2)
Abstract (n = 2)
Protocol (n = 2)
Not English (n = 1)

Studies included inqualitative synthesis(n = 8)(9 studies)

Studies included inquantitative synthesis(meta-analysis)(n = 8)(9 studies)

Figure 1. PRISMA flow diagram for article selection.

search. Of these, the full texts of 1,854 studies werescreened, and 8 RCTs with 9 studies met the inclusion criteria for this review (Caplan, Williams, Daly, & Abraham,
2004; Jansen et al., 2011; Lampela, Hartikainen, Lavikainen,
Sulkava, & Huupponen, 2010; Stolle, Wolter, Roth, & Rothgang, 2012; Parsons, Rouse, Robinson, Sheridan, & Connolly, 2012; Parsons, Sheridan, Rouse, Robinson, & Connolly, 2013; Rosted, Poulsen, Hendriksen, Petersen, & Wagner, 2013; Senior, Parsons, Kerse, Chen, Jacobs, Hoorn, &Anderson, 2014; Wong & Yeung, 2015) (Figure 1). Twostudies (Chi et al., 2006; Suijker et al., 2016) were excluded
because of incorrect intervention patterns such as preventive
interventions for healthy older adults.

4 of 17

Characteristics of the Reviewed Studies
The reviewed studies were published in seven countries:
Australia (Caplan et al., 2004), Hong Kong (Wong & Yeung,2015), Germany (Stolle et al., 2012), the Netherlands (Jansen et al., 2011), Finland (Lampela et al., 2010), New Zealand (Parsons et al., 2012; 2013; Senior et al., 2014), andDenmark (Rosted et al., 2013). All RCTs set up two arms
for the intervention and control groups. The duration of theinterventions was noted to vary from 2 months (Wong &Yeung, 2015) to 24 months (Senior et al., 2014). The mean
age of the participants ranged from 63.6 years (Jansen et al.,2011) to 82.1 years (Caplan et al., 2004). The sample size
varied from a minimum of 99 pairs of community-dwellingolder adults with dementia symptoms and their caregivers

https://doi.org/10.53044/jinr.2021-0018(Jansen et al., 2011) to a maximum of 1,000 older adults(Lampela et al., 2010). One study had a small sample sizewith fewer than 100 participants (Jansen et al., 2011).
The inclusion criteria of the participants in each study
were as follows: community-dwelling older adults, aged 65
years and older, in new referrals for homecare rehabilitations
in New Zealand (Parsons et al., 2012; 2013); older adults,
aged 65 or older, who have early symptoms of dementia in
the Netherlands (Jansen et al., 2011); frail and at high riskof institutionalization individuals, 65 years or older (!
55
years for one city), in New Zealand (Senior et al., 2014); urban and rural homecare users in Germany (age restriction
was not reported) (Stolle et al., 2012); those 70 years andolder who were at increased risk of functional decline andreadmission and who were discharged home within 3 daysof an emergency department admission in the capital regionof Denmark (Rosted et al., 2013); those 75 years and older
discharged home from an emergency department in Australia(Caplan et al., 2004); older adults in regional hospitals who
have the ability to communicate and/or slight to moderate
neurological deficit/disability and were discharged homeamong stroke survivors in Hong Kong (Wong & Yeung,2015) (age was not restricted); and a home-dwelling subpopulation of the large geriatric multidisciplinary strategy
for good care of the elderly study in eastern Finland involving only those aged 75 years and older (Lampela et al.,2010). The comparator received standard emergency care
(Caplan et al., 2004; Rosted et al., 2013;), usual community/
nursing home services (Senior et al., 2014; Stolle et al.,2012; Jansen et al., 2011; Lampera et al., 2010; Parsons etal., 2012; 2013), and hospital-based stroke physical training
for 3 weeks after hospital discharge (Wong & Yeung, 2015;
Lampera et al., 2010) (Table 1).
Settings, Care, and Care Providers
All the reviewed studies compared the comprehensive assessment tool used and simultaneously provided care services such as case-managed restorative care delivered withinboth residential care facilities and at home (Senior et al.,2014): coordinating functions consisting of assessment, advice, planning coordination, organizing collaboration, andmonitoring of care by geriatric specialist nurses (Jansen etal., 2011); team implementation or coordinated care recommendations (Caplan et al., 2004), problem-solving interventions (Rosted et al., 2013); improving or stabilizing functional abilities, cognitive skills, and QOL; reducing institutionalization (Stolle et al., 2012); interdisciplinary primarycare such as adjustment of medication and evaluation of theindications for all drugs in use (Lampela et al., 2010); restorative social support and physical function with rehabilitation services (Parsons et al., 2012; 2013); and providing
holistic care for stroke survivors (Wong & Yeung, 2015).
The targeted participants were older adults who were sent

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home from the emergency department (Caplan et al., 2004;
Rosted et al., 2013). Lampela et al. (2010), Parsons et al.
(2012, 2013), Stolle et al. (2012), and Wong and Yeung(2015) explored community-dwelling older adults. Senior etal. (2014) targeted frail older adults at residential care facilities or in homecare for by a multidisciplinary team. In a
study by Jansen et al. (2011), primary care practitioners
were the first to be visited in case of health problems, andthey are considered to play the role of gatekeepers in the
Dutch health system, controlling access to specialized care.
District nurses specializing in geriatric care acted as casemanagers. They coordinated various functions including assessment, providing advice and information, planning, coordinating, organizing, collaborating, and monitoring of care.
Wong and Yeung (2015) provided nurse-led care coordination and evaluation.
Types of Assessment Tools and Interventions
The types of assessment tools used in these studies were as
follows: Two studies used Comprehensive Geriatric Assessment (CGA) (Caplan et al., 2004; Lampela et al., 2010).
The Resident Assessment Instrument (RAI) as the minimum
data set for homecare (MDS-HC) (Stolle et al., 2012), RAIhomecare (HC) (Jansen et al., 2011; Senior et al., 2014),
and the RAI to achieve realistic goals on the elderly tool
(TARGET) (Parsons et al., 2012; 2013) were used to assess
adults and older adults. Another study targeted the standard
evaluation and intervention for seniors at risk (SEISAR)(Rosted et al., 2013) and the Omaha system (Wong & Yeung, 2015) with a total of 3,447 adults and older participants (Table 1). CGA is known to be a multidimensional,
interdisciplinary diagnostic process that focuses on determining the medical, psychosocial, and functional capabilitiesof older adults to provide a coordinated and integrated planfor treatment and long-term follow-up (Rubenstein et al.,1991). It involves the evaluation of functional status, such as
ADL, IADL, cognition, depression, nutrition, falls, social relations, and family caregivers’ burden. The RAI-HC (Morris
et al., 2009) assesses five key areas of function in older
adults, namely, functional performance, sensory performance, mental health, health problems, and service oversight.
It assesses an individual’s need for care and uses a computerized multidimensional instrument that consists of a minimum dataset (MDS) to assess the general functioning of thepatient and client assessment protocols, providing protocols
for the management of 30 potential and actual problem areas. Participants and nurses confirmed the problems andthereafter formulated care plans (Landi et al., 2000). The
TARGET incorporates cognition, nutrition, functional ability,
vision and hearing, continence, and informal care. This tool
facilitates the development of a client-generated goal and thesteps necessary for attainment (Parsons & Parsons, 2012). Ina study by Person et al. (2012; 2013), TARGET, which as5 of 17

6 of 17To explore the changesof medication as part of a
CGA as well as their adherence over 1 year,
during which time thepatients used the services
provided by standard(i.e., non-study) healthcare providers.

To determine the impactof a restorative model ofhome care on social support and physical function rehabilitation amongcommunity-dwellingolder people.

12 months

12 months

6 months

RCT,
2 armsRCT,
2 armsClusterRCT,
2 armsJansen, et al.,2011, The
Netherlands

Lampela, et al.,2010, FinlandParsons, et al.,2012; 2013,
New Zealand

To compare the effectsof case management andUC among community-dwelling older adults
with early symptoms ofdementia and their primary informal caregivers.

To study the effects of
CGA and multidisciplinary intervention onelderly patients sent
home from the ED.

18 months

RCT,
2 armsPurpose of the study

Caplan, et al.,2004, Australia

Durationof intervention

Type of
RCT,
arm

Authors, year of
publication, andcountry of origin

Table 1. Characteristics of the reviewed articles.

The assessor used the tool for an ADL element andgoal-setting; TARGET with combination of interRAI assessment: MDS-HC or MDS-contact assessment during
the initial assessment process of the participants to establish the aims of the rehabilitation episode. A standardized
CGA; the Support Needs Assessment (SNA) tool, including cognition, informal caregiver stress, safety, and nutrition; Nottingham extended activities of daily living scale(NEADL); and the EuroQoL 5D were performed.

Patients in the intervention group underwent a CGA conducted by the study team, which included two physicians(trainees in geriatrics), two nurses, two physiotherapists(for exercise counselling, strength and balance training in
the gym), and a nutritionist.

The RAI-HC was assessed by district nurse at the primarycare setting for both older adults and informal caregivers
for 12 months of case management.

Patients randomized to the treatment group underwent
initial CGA and were followed at home for up to 28 days
by a hospital-based multidisciplinary outreach team. The
team implemented or coordinated recommendations.

Type of assessment tool and intervention

n = 739
Aged 75 and older discharged home from ED.
Intervention groupn = 370, Mean age = 82.1 (SD 6.6) yeas old, Female =60.0%
Control groupn = 369, Mean age = 82.4 (SD 5.2) years old, Female =61.0%
Go home after randomization with no alteration to the discharge plan formulated by the medical officer in ED (UC).
n = 99Ninety-nine pairs of community-dwelling older adults withdementia symptoms and their primary informal caregivers
Intervention groupn = 54, mean age = 63.6 (SD 13.8) years old, Female n = 36
Control groupn = 45, mean age = 61.6 (SD 15.2) years old, Female n = 33
UC in the Netherlands comprehends a diversity of healthcare
and welfare services.
n = 1,000
Intervention Groupn = 500, 75–79 years old = 54.4%, 80–84 years old = 29.3%,
85+ years old = 16.3%.
Control groupn = 500, 75–79 years old = 48.6%, 80–84 years old = 31.6%,
85+ years old = 19.8%.
They received standard care with the possibility of visiting
local health centers, hospitals, or private practitioners whenneeded.
n = 205
Intervention groupn = 108, Mean age = 79.1 (SD 6.9) years old, Female =71.3%
Control Groupn = 97, Mean age = 76.9 (SD 7.6) years old, Female =60.8%
UC as the participants received a standard needs assessmentthat informed the delivery of home care services

Participant characteristics

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24 months

RCT,
2 armsClusterRCT,
2 armsRCT,
2 armsSenior, et al.,2014,
New ZealandStolle, et al.,2012, Germany

Wong & Yeung,2015,
Hong Kong,
China
To test the effectivenessof a TCP, which was anurse-led 4-week program designed based on
an assessment-intervention evaluation withstroke clients using the
Omaha system framework.

Assessing RAI can help
to improve or stabilize
functional abilities andcognitive skills, improve
quality of life, and reduce institutionalization,
thereby increasing outcome quality.

To examine the effect ofa two-stage nursing assessment and intervention to address older
adults’ uncompensatedproblems and thus intend
to prevent readmission
and functional decline
immediately following
discharge from the ED.
To evaluate the effectiveness of a restorative
care service on institution-free survival andhealth outcomes in frail
older people referred forneeds assessment in New
Zealand.

Purpose of the study

Used the Omaha system and substantiated it withstroke-specific content to guide the delivery of holisticcare in the TCP. To strengthen the interventions to address
the specific needs of stroke survivors, the study incorporated six specific domains of care in the scheme: (i) management and prevention of stroke recurrence; (ii) symptom assessment and management; (iii) enhancing physicalfunction—self-care abilities and exercise; (iv) healthy behavior—adherence to medication and diet; (v) building
resilience—connections with the self and family, a social
life, and a higher being; and (vi) emotion management.

n = 105
Intervention groupn = 52, Mean age = 81.9 (SD 6.8) yeas old, Female = 51.9%
Control groupn = 53, Mean age = 83.6 (SD 6.9) years old, Female =56.6%
UC that included community services or permanent placement in residential care were assessed and service coordinated by a centrally based needs coordinator.

The program models promoting independence provide
case-managed restorative care delivered within both residential care and at home by a multidisciplinary team,
based on home treatment teams. Older people who wereassessed as being too unstable to return home immediately
on hospital discharge or on referral from the community
were offered a short-stay needs assessed rehabilitation inresidential care with the goal to restore function and return
the older person to living in the community. interRAI-HC
ver.2.03 was used for assessment.
The entire home care services team in the treatment group
received training in RAI of 6 h over a period of 4 weeks.
They were responsible for the implementation of RAI.

920 clients with 69 home care service providers throughout
Germany
Intervention groupn = 543 from 36 nursing home service providers, mean age =80.0 years old, female = 64.9%.
Control groupn = 377 from 33 nursing home service providers, mean age =77.5 years old, female = 64.4%.
Provided UC
n = 108
Mean age = 69.5 (SD 11.8) years old, Female = 63%
Intervention groupn = 54, Mean age =67.5 (SD 11.6) years old, Female = 63%
Control groupn = 54, Mean age =71.5 (SD 11.6) years old, Female = 63%
Provide only hospital-based rehabilitationn = 271
Intervention groupn = 141, Mean age = 81.4 (SD 6.5) years old, Female = 69%
Control groupn = 130, Mean age = 82.7 (SD 6.7) years old, Female = 64%
The control group received the standard ED discharge planning that comprised routine notification of the older persons’respective community health centers if patients needed homecare services following discharge.

Participant characteristics

The SEISAR tool was used for assessment, which is astandardized nursing assessment with a checklist of 10
medical, social, emotional, and physical items took theform of a conversation during which all 10 items werediscussed in an older that suited the participant. The research nurses carried out the problem solving intervention.

Type of assessment tool and intervention

Notes: RCT, randomized controlled trials; SD, standard deviation; ED, emergency department; TCP, transitional care program; UC, usual care; CGA, Comprehensive Geriatric Assessment; RAI-HC,
Resident Assessment Instrument- Home Care; MDS-HC, Minimum Dataset- for Home Care; TARGET, toward achieving realistic goals in elders tool; SEISER, Standardized Evaluation and Intervention for Seniors at Risk

2 months

13 months

6 monthsA
simpleRCT,
2 arms

Rosted, et al.,2013, Denmark

Durationof intervention

Type of
RCT,
arm

Authors, year of
publication, andcountry of origin

Table 1. Characteristics of the reviewed articles (continued).

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Table 2. Risk of bias assessment in each study.

Caplan, et al., 2004
Jansen, et al., 2011
Lampela, et al., 2010
Parsons, et al., 2012, 2013
Rosted, et al., 2013
Senior, et al., 2014
Stolle, et al., 2012
Wong & Yeung, 2015

Randomization
process

Deviation from
intendedinterventions

Missing
outcome data

Measurementof the outcome

Selection of
the reported
resultOverallHigh risk
Low risk
Low risk
Low risk
Low risk
High risk
Some concerns
Low riskSome concerns
Low riskSome concerns
Low risk
Low risk
Low riskSome concerns
Low risk

High risk
Low risk
High risk
Low risk
Low risk
Low risk
High risk
Low risk

High risk
Low risk
Low risk
Low risk
Low riskSome concerns
Low risk
Low riskSome concerns
Low riskSome concerns
Some concerns
Some concerns
Low riskSome concerns
Some concerns

High risk
Low risk
High risk
Some concerns
Some concerns
High risk
High risk
Some concerns

sesses ADL elements and is a goal-setting tool, was combined with the inter-RAI, MDS-HC, or MDS-CONTACT assessment datasets. The SEISAR is a short, standardized, andcomprehensive tool for evaluating active geriatric problems
in older adults in the ED. The SEISAR tool is an actionoriented checklist that incorporates recommendations for themost appropriate intervention (McGill University, 2017). The
Omaha system is described as an assessment-interventionevaluation framework with a comprehensive assessment
framework comprising four domains (Martin, 2005). It wasdeveloped in the 1970s, and further research was conducted
to establish its reliability, validity, and usability between
1989 and 1993 (Martin, 2005). All interventions involved
the physical, psychological, and social aspects of care forolder adults.

2004; Lampela et al., 2010; Parsons et al., 2012; 2013;
Stolle et al., 2012; Wong & Yeung, 2015), and no outcomes
were reported in the protocol (Rosted et al., 2013). The
overall risk of bias of the selected studies showed either
high risk or some concerns, except for one low-risk study.
Synthesis of Results
The primary and secondary outcomes were synthesized (Table 3). Other outcomes (ADL) could not be integrated because they reported different outcome measures or did notprovide or calculate the SD results. A meta-analysis was
performed to compare the use of assessment tools with thatof the control group for each outcome. The results of thesensitivity analysis in adherence and emergency department
visits did not identify differences.

Risk of Bias in the Included Studies

Adherence of Intervention

A summary of the risk of bias in each study is presented inTable 2. All studies reported randomization processes; however, two studies (Caplan et al., 2004; Senior et al., 2014)
showed a high risk, whereas one study (Stolle et al., 2012)
showed some concerns in the random generation process because of the lack of allocation concealment. Three studies(Caplan et al., 2004; Lampela et al., 2010; Stolle et al.,2012) had some concerns regarding deviations from intended interventions due to the lack of intention-to-treat andthe substantial impact of failure. The same three studies
were found to have a high risk of blinding of participants
and personnel and no information on missing outcome data.
One study (Caplan et al., 2004) had a high risk of bias as aconsequence of not being blinded to outcome assessors, andone study (Senior et al., 2014) had some concerns with regard to the outcome measurement, as it was not influenced
by the knowledge of intervention by use of health service
utilization. Six studies (Caplan et al., 2004; Lampela et al.,2010; Parsons et al., 2012; 2013; Rosted et al., 2013; Stolle
et al., 2012; Wong & Yeung, 2015) showed some concerns
regarding the selection of the reported result because no
study protocol was found in five studies (Caplan et al.,Adherence was evaluated in all studies (Caplan et al., 2004;
Jansen et al., 2011; Lampela et al., 2010; Parsons et al.,2012; 2013; Rosted et al., 2013; Senior et al., 2014; Stolle
et al., 2012; Wong & Yeung, 2015) and integrated into a
meta-analysis. No significant difference was in terms of adherence between the assessment tool use and control groups(RR = 1.04; 95% CI = 0.99-1.08; p =.11) (I2 = 12%; Figure2).

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Quality of Life
Two RCTs (Rosted et al., 2013; Wong & Yeung, 2015) were
evaluated for health-related QOL using the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12)
and 36-item (SF-36) survey and were integrated into themeta-analysis. For physical QOL, statistical heterogeneity
was observed between groups (I2 = 97%). However, a significant difference was noted in mental state QOL between
the assessment tool use and control groups (RR = 0.26; 95%
CI = 0.06-0.46; p =.01) (I2 = 0%; Figure 3).
Emergency Department Visit
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Table 3. Homecare assessment studies and the reported clinical outcomes.
Numberof studies

Total numberof participants

Primary outcome
Adherence

8

3,447

Caplan, et al., 2006; Jansen, et al., 2011; Lampela, et al., 2010; Parsons, et al.,2012, 2013; Rosted, et al., 2013; Senior, et al., 2014; Stolle, et al., 2012;
Wong & Yeung, 2015

Secondary outcomes
ADL
QOL
Emergency department visit
Number of hospital admissions
Nursing home admissions
Mortality

1
2
2
3
3
4

108
379
847
1,118
1,115
1,320

Wong & Yeung, 2015
Rosted, et al., 2013; Wong & Yeung, 2015
Caplan, et al., 2004; Wong & Yeung, 2015
Caplan, et al., 2004; Rosted, et al., 2013; Wong & Yeung, 2015
Caplan, et al., 2004; Rosted, et al., 2013; Senior, et al., 2014
Caplan, et al., 2004; Parsons, et al., 2012, 2013; Rosted, et al., 2013; Senior,
et al., 2014

Clinical outcomes

Reference

Notes: ADL, activities of daily living; QOL, quality of life

evaluated for emergency department visits. Statistical heterogeneity was observed between groups (I2 = 75%); therefore,
we could not synthesize the data. Caplan et al. (2004) reported that the intervention and control groups showed nodifference in terms of emergency department visits during
the study period (15.7% versus 13.3%, respectively; 95% CI−2.7%-7.5%, p =.349); however, Wong and Yeung (2015)
reported that emergency room visits were significantly lower
in the intervention group at 8 weeks (1.9% versus 13.0%,
respectively, in the intervention and control groups, χ2=
4.86, df = 1, p =.027).
Hospital Admission
Three RCTs (Caplan et al., 2004; Rosted et al., 2013; Wong
& Yeung, 2015) were evaluated for number of hospital admissions. No significant difference was determined in termsof the admission ratio between the assessment tool use andcontrol groups (RR = 0.88; 95% CI = 0.70-1.11; p =.29) (I2= 0%; Figure 4).
Nursing Home Admission
Three RCTs (Caplan et al., 2004; Rosted et al., 2013; Senior
et al., 2014) were evaluated for the ratio of nursing homeadmissions. No significant difference was found in the admission ratio between the assessment tool use and control
groups (RR = 0.94; 95% CI = 0.67-1.31; p =.70) (I2 = 0%;
Figure 5).
Mortality
Four RCTs (Caplan et al., 2004; Parsons et al., 2012; 2013;
Rosted et al., 2013; Senior et al., 2014) were evaluated for
mortality. As per our findings, no significant difference wasnoted in mortality between the assessment tool use and control groups (RR = 0.99; 95% CI = 0.74-1.33; p =.96) (I2 =0%; Figure 6).

Certainty of Evidence
The certainty of the evidence for each outcome is presented
in Table 4. Eight studies were synthesized for the metaanalysis of five outcomes. According to the assessment, certainty of the evidence was found to be low in adherence,
emergency department visits, hospital admissions, and nursing home admissions and moderate certainty in QOL andmortality. The lower certainty was caused by the nonconcealed allocation, non-blinded outcome measurement,
non-reported missing outcome data, imprecision due to thesmall study participant numbers, inconsistency denoted byhigh heterogeneity of results, and indirectness of heterogeneity in subjects’ diseases.

Discussion
Characteristics and Quality of RCTs
Only eight RCT studies were available within the inclusion
criteria; half of the studies were conducted in Europe (n =4), while the others were conducted in Asia (n = 1) andOceania (n = 3). The number of eligible participants was
3,447, which is slightly limited. All studies were publishedbetween 2004 and 2015. We identified only six outcomesthat were statistically integrated because of different measurement tools used, tools were not provided, or SDs could
not be calculated. The randomization process and missing
outcome data were considered in the studies, and the overallcertainty of evidence in this review ranged from very low tomoderate.
Summary of Intervention
All the reviewed studies involved the use of a comprehensive assessment tool and provision of care services beyond
the usual care based on the assessment. Most homecare
service providers highly recommend case management and
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Risk Ratio
M-H, Random, 95% CI

Experimental
Control
Risk Ratio
Study or Subgroup
Events Total Events Total Weight M-H, Random, 95% CI
1.1.1 CGA
Caplan et al., 2004
294
370
282 369 23.6%
1.04 [0.96, 1.12]
Lampela et al., 2010
371
500
346 500 23.0%
1.07 [0.99, 1.16]
Subtotal (95% CI)
870
869 46.5%
1.06 [1.00, 1.11]
Total events
665
628
Heterogeneity: Tau2 = 0.00; Chi2 = 0.31, df = 1 (p = .58); I2 = 0%
Test for overall effect: Z = 1.94 (p = .05)
1.1.2 OMAHA
Wong & Yeung 2015
48
54
Subtotal (95% CI)
54
Total events48
Heterogeneity: Not applicable
Test for overall effect: Z = 0.83 (p = .41)

45

54
54

7.2%
7.2%

45

1.1.3 RAI-HC, MDS-HC
Jansen et al., 201143
54
38 45 5.0%
Senior et al., 2014852
5 53 0.2%
Stolle et al., 2012
136277
110 192 5.8%
Subtotal (95% CI)
383
290 11.0%
Total events
187
153
Heterogeneity: Tau2 = 0.00; Chi2 = 1.80, df = 2 (p = .41); I2 = 0%
Test for overall effect: Z = 1.60 (p = .11)
1.1.4 TARGET+RAI+MDS-HC
Parsons et al., 2012 2013
65
66
Subtotal (95% CI)
66
Total events
65
Heterogeneity: Not applicable
Test for overall effect: Z = 1.43 (p = .15)
1.1.5 SEISAR
Rosted et al., 2013
113
141
Subtotal (95% CI)
141
Total events
113
Heterogeneity: Not applicable
Test for overall effect: Z = 0.34 (p = .73)

1.07 [0.92, 1.24]
1.07 [0.92, 1.24]

55

0.94 [0.78, 1.13]
1.63 [0.57, 4.66]
0.86 [0.72, 1.02]
0.90 [0.80, 1.02]

59 24.4%
59 24.4%

1.06 [0.98, 1.14]
1.06 [0.98, 1.14]

102 130 10.8%
130 10.8%
102

1.02 [0.90, 1.15]
1.02 [0.90, 1.15]

55

Total (95% CI)
1514
1402 100.0%
1.04 [0.99, 1.08]
Total events
1078
983
Heterogeneity: Tau2 = 0.00; Chi2 = 7.95, df = 7 (p = .34); I2 = 12%
Test for overall effect: Z = 1.59 (p = .11)
Test for subgroup differences: Chi2 = 5.55, df = 4 (p = .24), I2 = 27.9%

0.5 0.71
1.5 2
Favours [experimental] Favours [control]

Figure 2. Forest plot of comparison for primary outcome (adherence of intervention and completion of follow-up): homecare assessment tool use versus usual care for the adherence.

Experimental
Control
Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI
1.2.1 SF-12 (MCS)
Rosted et al., 201353.1 9.6 141 50.9 11.9 130 71.8% 0.20 [-0.04, 0.44]
Subtotal (95% CI)
141
130 71.8% 0.20 [-0.04, 0.44]
Heterogeneity: Not applicable
Test for overall effect: Z = 1.67 (p = .09)
1.2.2 SF-36 (MCS)
Wong & Yeung, 2015 49.9
1 54 49.4 1.4
Subtotal (95% CI)
54
Heterogeneity: Not applicable
Test for overall effect: Z = 2.10 (p = .04)

54 28.2%
54 28.2%

0.41 [0.03, 0.79]
0.41 [0.03, 0.79]

Total (95% CI)
195
184 100.0%
Heterogeneity: Tau2 = 0.00; Chi2 = 0.79, df = 1(p = .37); I2 = 0%
Test for overall effect: Z = 2.53 (p = 0.01)
Test for subgroup differences: Chi2 = 0.79, df = 1(p = .37), I2 = 0%0.26 [0.06, 0.46]

Std. Mean Difference
IV, Random, 95% CI

-1
-0.5
0
0.5
1
Favours [experimental] Favours [control]

Figure 3. Forest plot of comparison for secondary outcome (mental state of quality of life): homecare assessment tool use versus
usual care for the mental state of quality of life.

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Experimental
Control
Risk Ratio
Study or Subgroup
Events Total Events Total Weight M-H, Random, 95% CI
1.3.1 CGA
Caplan et al., 2004
42
370
51 369 37.5%
0.82 [0.56, 1.20]
Subtotal (95% CI)
370
369 37.5%
0.82 [0.56, 1.20]
Total events
42
51
Heterogeneity: Not applicable
Test for overall effect: Z = 1.01 (p = .31)
1.3.2 OMAHA system
Wong & Yeung, 2015
454
Subtotal (95% CI)
54
Total events
4
Heterogeneity: Not applicable
Test for overall effect: Z = 1.19 (p = .23)
1.3.3 SEISAR
Rosted et al., 2013
52
141
Subtotal (95% CI)
141
Total events
52
Heterogeneity: Not applicable
Test for overall effect: Z = 0.27 (p = .79)

8

54
54

4.2%
4.2%

0.50 [0.16, 1.56]
0.50 [0.16, 1.56]

130 58.3%
130 58.3%

0.96 [0.71, 1.30]
0.96 [0.71, 1.30]

Risk Ratio
M-H, Random, 95% CI

8

50
50

Total (95% CI)
565
553 100.0%
0.88 [0.70, 1.11]
Total events
98
109
Heterogeneity: Tau2 = 0.00; Chi2 = 1.40, df = 2(p = .50); I2 = 0%
Test for overall effect: Z = 1.07 (p = .29)
Test for subgroup differences: Chi2 = 1.37, df = 2(p = .50), I2 = 0%

0.2
0.5
1
2
5
Favours [experimental] Favours [control]

Figure 4. Forest plot of comparison for secondary outcome (hospital admission): homecare assessment tool use versus usual carefor the hospital admission.

Experimental
Control
Risk Ratio
Study or Subgroup Events
Total Events Total Weight M-H, Random, 95% CI
1.4.1 CGA
Caplan et al., 2004
32
370
28 369 47.5%
1.14 [0.70, 1.85]
Subtotal (95% CI)
370
369 47.5%
1.14 [0.70, 1.85]
Total events
32
28
Heterogeneity: Not applicable
Test for overall effect: Z = 0.53 (p = .60)
1.4.2 SEISAR
Rosted et al., 2013
5141
Subtotal (95% CI)
141
Total events
5
Heterogeneity: Not applicable
Test for overall effect: Z = 0.44 (p = .66)

6

130
130

8.3%
8.3%

0.77 [0.24, 2.46]
0.77 [0.24, 2.46]

53 44.2%
53 44.2%

0.79 [0.48, 1.30]
0.79 [0.48, 1.30]

Risk Ratio
M-H, Random, 95% CI

61.4.3 RAI-HC, MDS-HC
Senior et al., 20141752
22
Subtotal (95% CI)
52
Total events
17
22
Heterogeneity: Not applicable
Test for overall effect: Z = 0.93 (p = .35)

Total (95% CI)
563
552 100.0%
0.94 [0.67, 1.31]
Total events
54
56
Heterogeneity: Tau2 = 0.00; Chi2 = 1.21, df = 2 (p = .54); I2 = 0%
Test for overall effect: Z = 0.38 (p = .70)
Test for subgroup differences: Chi2 = 1.19, df = 2 (p = .55), I2 = 0%

0.2
0.5
1
2
5
Favours [experimental] Favours [control]

Figure 5. Forest plot of comparison for secondary outcome (nursing home admission): homecare assessment tool use versus usual
care for the nursing home admission.

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Experimental
Control
Risk Ratio
Study or Subgroup
Events Total Events Total Weight M-H, Random, 95% CI
1.5.1 CGA
Caplan et al., 2004
55
370
53 369 69.8%
1.03 [0.73, 1.47]
Subtotal (95% CI)
370
369 69.8%
1.03 [0.73, 1.47]
Total events
55
53
Heterogeneity: Not applicable
Test for overall effect: Z = 0.19 (p = .85)
1.5.2 SEISAR
Rosted et al., 201313
141
Subtotal (95% CI)
141
Total events
13
Heterogeneity: Not applicable
Test for overall effect: Z = 0.69 (p = .49)
1.5.3 RAI-HC, MDS-HC
Senior et al., 20141052
Subtotal (95% CI)
52
Total events
10
Heterogeneity: Not applicable
Test for overall effect: Z = 0.87 (p = .38)
1.5.4 TARGET+RAI+MDS-HC
Parsons et al., 2012 2013
066
Subtotal (95% CI)
66
Total events0
Heterogeneity: Not applicable
Test for overall effect: Z = 1.12 (p = .26)

9130 12.7%
130 12.7%

1.33 [0.59, 3.01]
1.33 [0.59, 3.01]

53 16.6%
53 16.6%

0.73 [0.36, 1.49]
0.73 [0.36, 1.49]

59
59

0.18 [0.01, 3.66]
0.18 [0.01, 3.66]

Risk Ratio
M-H, Random, 95% CI

9

14
14

2

0.9%
0.9%

2

Total (95% CI)
629
611 100.0%
0.99 [0.74, 1.33]
Total events
78
78
Heterogeneity: Tau2 = 0.00; Chi2 = 2.51, df = 3 (p = .47); I2 = 0%
0.002
0.1
1
10
500
Test for overall effect: Z = 0.05 (p = .96)
Favours [experimental] Favours [control]
Test for subgroup differences: Chi2 = 2.51, df = 3 (p = .47), I2 = 0%

Figure 6. Forest plot of comparison for secondary outcome (mortality): homecare assessment tool use versus usual care for the
mortality.

care coordination to appropriately solve problems, improveolder adults’ functional abilities and cognitive skills, and improve their QOL. Interdisciplinary primary care has beensuggested to reduce institutionalization and improve homecare.
Regarding the assessment tools used in the reviewed studies, two studies used CGA, which is well developed for interdisciplinary geriatric care settings. RAI-HC, MDS-HC,
and the Omaha system were originally developed to improve
the quality of homecare assessment and care plans, whereas
the SEISER was developed for standardized nursing assessment. The TARGET was assessed only in terms of the ADLof older adults; therefore, the RAI-HC and MDS datasets
were combined for additional assessment. However, we
could not compare the effectiveness of these tools in this review because of the limited integration results. All RCTs set
two arms for the intervention and control groups, although
the comparator exhibited a variety of types such as emergency care, hospital-based rehabilitation, community-based,
and nursing home services. The intervention and follow-up
duration showed some differences; three studies were lessthan 6 months, while another study showed 12 to 24
months. Meta-analysis showed no significant subgroup differences. The healthcare providers included nurses, district
12 of 17nurses, research nurses, nurses and physiotherapist teams,
physicians, and needs assessment/interdisciplinary outreachand research teams. Based on these results, nurses play a
key role in the initial comprehensive assessment and leadthe homecare team. The interventions in these reviewed
studies have the potential for clinical heterogeneity in thetarget participants, provided care, and case management details. Consequently, no statistical heterogeneity was noted interms of adherence, mental QOL, hospital/nursing home admission, and mortality. Compared with the control group,
the RAI-HC and MDS-HC subgroups showed excessive participant withdrawal in the intervention group.
Summary of Participants
The youngest among the participants was in the RAI-HC
study in the Netherlands (Jansen et al., 2011), whereas theoldest was the CGA study in Australia (Caplan et al., 2004)
and RAI-HC study in New Zealand (Senior et al., 2014), in
which most participants showed functional and/or cognitive
decline. Compared to the two studies by Senior et al. (2014)
and Jansen et al. (2011), the oldest intervention group
showed 56% loss to follow-up within 12 months, and 85%
were lost to follow-up within 24 months (Senior et al.,2014). This indicates that the older participants’ prognosis

197 per 1,000
101 per 1,000
123 per 1,000

Hospital admission
Nursing home admission
Mortality

170 per 1,000 (134–215)
97 per 1,000 (70–137)
118 per 1,000 (89–158)

699 per 1,000 (672–727)
SMD 0.26 SD (0.06 to 0.46)
Not pooled

Risk with homecare assessment tool use

RR 0.86 (0.68–1.09)
RR 0.96 (0.69–1.35)
RR 0.96 (0.72–1.28)

RR 1.01 (0.97–1.05)
Not pooled

Relative effect(95% CI)

1,118 (3 RCTs)
1,115 (3 RCTs)
1,320 (4 RCTs)

3,447 (8 RCTs)
379 (2 RCTs)
877 (2 RCTs)

No. of participants (studies)⊕⊕◯◯ Lowd⊕⊕◯◯ Lowd⊕⊕⊕◯ Moderatee⊕⊕◯◯ Lowa⊕⊕⊕◯ Moderateb⊕⊕◯◯ Lowc

Certainty of theevidence (GRADE)

Statistical heterogeneity was observed (I2 = 75%).
Caplan et al. (2004): 15.7% vs 13.3% (p = .349) andWong & Yeung (2015): 1.9% vs 13.0% (intervention and control group, respectively) (p = .027) visited emergency department during study period.

Comments

a. Downgraded by two levels: two level for serious risk of bias.
b. Downgraded by one level for imprecision denoted by the small sample size.
c. Downgraded by two levels: one level for serious risk of bias and one level owing to inconsistency denoted by high heterogeneity of results (I2 = 75%).
d. Downgraded by two levels: one level for serious risk of bias, and one level owing to indirectness by heterogeneity in the subjects’ diseases.
e. Downgraded by one level for indirectness by heterogeneity in the subjects’ diseases.

GRADE Working Group grades of evidenceHigh certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Notes: *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; SMD: standardized mean difference; QOL: quality of life

692 per 1,000
Not pooled

Risk withusual care

Anticipated absolute effects* (95% CI)

Adherence
QOL
Emergency department
visit

OutcomesPatient or population: older adults, Setting: homecare, Intervention: Homecare assessment tool use, Comparison: usual care

Homecare assessment tools compared to usual care for older adults

Table 4. Summary of findings.

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may have been more serious compared to the younger
group, with only 20.3% loss at 12 months of follow-up(Jansen et al., 2011). Furthermore, care needs often vary depending on age, functional decline, and frailty; consequently,
the characteristics of the participants may impact the results.
Summary of EvidenceThis meta-analysis showed that using comprehensive assessment tools, including the nurse-led assessment of older
adults’ physical functioning, disease, and health state, andsocial functioning, based on a detailed assessment, nurse’s
problem-solving intervention, or delivery of holistic care ina transitional care program, was found to be more effective
than standardized emergency discharge planning alone or theprovision of hospital-based rehabilitation programs only for
improving mental QOL. The results may be particularly
noteworthy concerning intervention; however, the certaintyof the evidence (GRADE) was low for adherence, emergency department visits, and hospital/nursing home admission and moderate for QOL and mortality; therefore, we
downgraded the results due to these imprecisions. Moreover,the sensitivity analysis is robust to the decisions made inthis review.
In terms of improving people’s QOL, as the origin of
homecare, evidence is scarce, and more research is neededin this field. We found no intervention effects on any of the
primary/secondary outcomes in terms of adherence, ADL,
physical QOL, emergency department visits, hospital admission, nursing home admission, or mortality. Moreover, we
could not determine an effective intervention period. Studies
that represented nurse-led assessments and interventions
have been observed to improve mental QOL. Nonetheless,the type of interdisciplinary team and the physical state ofolder adults could not be clearly discussed in this review,
owing to the small number of studies.
This review concludes that the use of nurse-led comprehensive homecare assessment tools has the potential to improve mental QOL for older adults with medical conditions
and to improve assistance services from the community ifprovided with case management. As suggested via selection
bias, the results may differ for different target conditiongroups. The age of the participants with acute and chronic
diseases showed a wide range of approximately 20 years.
The demand for community services is considered to differ
depending on common age-related changes. Moreover, in
this meta-analysis, interventions based on the assessment,such as enhancing physical functions, self-care behaviors
and medications, older adults’ physical functioning, cognitive and mental state, and family caregiver burden, can makethe results prone to larger alpha errors, owing to multiple
comparisons. Nonetheless, the p-value for the outcomes ofmental QOL was found to be significant (p =.01).
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Implications for Homecare Assessment for Older Adults inPrimary CareIn the context of appropriate case management and careplanning in primary care, to improve the QOL of older people at home, it is suggested that nurse-led multi-domain observation and interviews should not only assess physicalproblems and specific care needs but also track theirstrength and QOL for satisfaction. Therefore, the community
care delivery system and multiple community resources havesignificantly improved mental QOL. Hence, using a comprehensive assessment tool may provide benefits by adding a
multi-domain understanding to problem-solving with casemanagement and reinforcing disease management. Moreover,the cost of community service delivery should be considered, specifically for older adults who may require multiple
care services for long durations with a financial burden.
Training nurses to assess older adults’ mental states, such as
depression, is also important for developing appropriate referrals and care for depressed patients (Bruce et al., 2007).
These opportunities can contribute to improving the qualityof homecare.
Owing to the increase in life expectancy, an aging population with diseases has also increased the demand for community care services (WHO, 2011). More than 50% of theparticipants in this review lived alone. The number and percentage of older people living alone are increasing in mostcountries (WHO, 2011). Therefore, these services can help
lessen social isolation.
Some distinct recommendations emerge from the results:(a) nurse-led homecare assessment for older adults suspected
to improve the mental QOL of older adults in the community; (b) incorporating case management, including physical,
mental, medical, and functions of daily life, based on an assessment of improved mental QOL; and (c) an interdisciplinary community care team is required for care delivery.
However, the results of this review provide relatively low
certainty of evidence regarding the effectiveness of using acomprehensive homecare assessment tool to improve outcomes. Thus, future studies may clarify these conclusions.
The use of assessment tools provides an opportunity to educate healthcare providers and improve the quality of care delivery in the community.
Limitations
We have only reviewed eight RCT studies, which were split
into six major tools; therefore, there was a risk of selection
bias. The small number of participants also suggests reporting bias. Owing to the multiple comparisons of tools andclinical interventions, significant pooled effects may emerge
as non-significant after statistical adjustment for multiple
comparisons. Therefore, the effect may have been overestimated and should be interpreted with caution. We could nothttps://doi.org/10.53044/jinr.2021-0018

determine which type of assessment tool would be appropriate for improving QOL. The certainty of the evidence of assessment tool use for case management was determined tobe limited; however, the use of assessment tools was demonstrated to be an indispensable approach to focus on careneeds, with no reported harmful results.
Conclusions
In total, 8 RCTs with 3,447 older adults in the community
were integrated into a meta-analysis that analyzed the effectiveness of a comprehensive assessment tool used for homecare to improve adherence, QOL, and health outcomes. Thismeta-analysis showed that the use of an assessment tool was
effective in terms of improving the mental QOL during caredelivery. However, there is currently insufficient evidence tosupport which tool would be useful for follow-up because it
has not been sufficiently shown to affect health outcomesfor homecare in the context of case management.
What Is Already Known about the Topic?
・Homecare demand and the use of health services have recently increased in our super-aged society. Standardized
homecare assessment in primary care settings is required
to extensively screen and assess older adults at home.
・Several types of comprehensive homecare assessment
tools have been used for the management of communitydwelling older adults at home and have been suggested tohave the potential to improve the prediction of clinicaloutcomes.
What This Study Adds
・This meta-analysis has showed that the use of a comprehensive assessment tool with case management has thepotential to improve the mental QOL of older adults receiving homecare; however, the certainty of the evidence
was found to be moderate. Adherence and other outcomes
showed no differences in the use of the assessment tools.
Further studies are required to confirm these findings.
Acknowledgments
The authors sincerely thank Ms. Kuniko Sato and Ms. Satoko Shindo, the librarians of St. Luke’s International University. The authors would also like to extend their gratitude
to the following people who served as literature screening
collaborators: Dr. Yasuko Igai, RN, St. Luke’s International
University; Mizuki Sakamoto, RN, Graduate School of
Nursing Science Master Course Student, St. Luke’s International University; Mayumi Miyazawa, RN, CNS, Special
Nursing Home Koufuen; and Dr. Chieko Kubota, PhD, Saitama Prefectural University.
This systematic review was registered with PROSPERO
from the National Institute for Health Research ID CRD
42021238737.

JINR 2023, 2(1), e2021-0018

Author Contributions
All authors contributed directly to this study. TK: study concept and design, literature database search, screen, text review and data integration, and drafting the manuscript. SE
and AK: database search of the literature with PI, text review, data integration and interpretation, and critical revisionof the manuscript. YT, AS, YU, YF, SK, KK, and SS:
screen, text review, data extraction, and critical revision of
the manuscript. SS supervised the assessment tools. All
authors approved the final version of the manuscript.
Declaration of Conflicting Interests
The authors declare they have no economic nor academic
conflict of interest for this study. Tomoko Kamei received
research fund from Nippon Telegraph and Telephone West;
this fund had no relations to this study nor conflict of interest to this study. Yoko Uchida received research fund fromjoint research fund between Gunma University and Shimoda
Industrial Corporation; thus, this fund had no relations tothis study nor conflict of interest to this study.
Funding
This study was funded by the Sasakawa Health Foundation,
Tokyo, Japan [Grant No.2020-14, Primary Researcher: Setsu
Shimanouchi.]
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https://www.jinr.jsnr.or.jp/

Original ResearchPhysiological and psychological effectiveness of facial massage inwomen: A randomized crossover trial
Yuriko Ohkawa, MSN1 , Hiroki Tanoue, PhD1 , and Kiyoko Fukai, PhD2
1

School of Nursing, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan, and 2The Jikei University Schoolof Nursing, Tokyo, Japan

Abstract
Objective: This study aimed to examine the effectiveness of facial massage, as a nursing technique, in alleviatingstress in healthy women using physiological and psychological indicators. Methods: A crossover design was employed; participants were 22 healthy females between the ages of 20 and 22. Participants were assigned to Sequence 1, wherein they received a 3-minute facial massage in Period I and 3-minute rest in Period II, or Sequence 2, which employed the reverse order. Participants’ blood pressure (BP), pulse rate, salivary alpha-amylase(sAA), Profile of Mood States (POMS), “Relaxation level,” “Comfort level,” and “Wakefulness level,” as measured by
the Visual Analog Scale (VAS), were assessed before and after the facial massage or resting intervention. Results: Between the two groups, changes in systolic BP increased in the facial massage group, but there was nodifference in pulse and sAA. While there was no difference between the two groups in the POMS, VAS scores revealed an increase in the “Relaxation level” and “Comfort level” in the facial massage group. Facial massage participants reported feeling “refreshed,” whereas the control group reported feeling “sleepy.” Conclusions: The 3minute facial massage increased relaxation with respect to psychological measures; however, BP change could
not explain stress reduction. (This study was enrolled in the UMIN as an intervention study and as a prospective
randomized crossover trial. The trial registration number is UMIN000033939.)
Keywords
crossover study, facial massage, relaxation, Visual Analog Scale, woman
JINR 2023, 2(1), e2021-0005

Introduction
In nursing care, massage therapy has been used as a means
to promote comfort and non-verbal communication for patients who present physical and psychological distress(Westman et al., 2016). In recent years, the effects of massage therapy have been investigated in both Japan and overseas, and it has been emphasized as a viable option in complementary and alternative therapies. While many studies
have focused on massage therapy for hands, feet, and back,there has been a paucity in research on the massage andcare of the face. It has been reported that comfort and relaxation―the psychological effects of a facial massage―areassociated with frontal lobe activity (Nakashima et al.,2010). Moreover, studies report that facial care for elderly
women can facilitate improvement in their activities of dailyliving and reduce tension and anxiety (Suga et al., 2015;
Machida, et al., 2012). Therefore, we believe that facial
massage therapy would be a useful tool in nursing care due
to its physical and psychological effects, and we are keen to
examine its effectiveness.
The facial region contains the skin, muscles, nerves, lym-

Correspondence: Y. Ohkawa. Email: yuriko_ookawa@med.miyazaki-u.ac.jp
Received: June 10, 2021, Accepted: January 20, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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phatic glands, and salivary glands, which undergo various
physiological changes, such as protection from the external
environment (e.g., antimicrobial protection of the skin) andsecretion of digestive enzymes (Nguyen and Duong, 2021).
Furthermore, the face has sensory organs such as the eyes,
nose, and mouth, which not only has important functions inmaintaining vital and bodily functions but also serves to reflect negative psychological effects such as chronic dissatisfaction, low self-esteem, and even depression (Kondo et al.,2005). We suppose that massaging the face, which has suchdiverse facets, can bring about psychological as well as
physiological benefits. Hatayama et al. (2008) reported thata facial massage activates the sympathetic nervous systemand has a refreshing rather than a relaxing effect. Ejindu(2007) found that the facial massage group induces more
drowsiness and lowered blood pressure (BP) than the footmassage group. However, the results of the present study
must be interpreted with caution due to problems with its
experimental process, such as the small sample size of six
participants and the unreported technique of massage.
In studies evaluating the effects of massage therapy, factors related to the stress response of the hypothalamicpituitary-adrenal system and autonomic nervous system havebeen measured as physiological indicators (Noto, Kitajima,
et al., 2010; Noto, Kudo, et al., 2010). These investigations
have provided evidence for the positive effects of massage
therapy, such as stress relief, relaxation, and immunity enhancement, and, additionally, its effectiveness for female patients with chronic illnesses such as cancer and depression(da Silva et al., 2017; Field, 2016; Ghesquiere et al., 2019;
Hernandez-Reif et al., 2004; Lee et al., 2015). In the present
study, we measured the effects of facial massage therapy using physiological and psychological indicators of the stressresponse.
Regarding the method of facial massage, the time andprocedure of implementation are varied in various studies.
The shortest massage duration was 1 min (Kawaguchiya etal., 2014), and the longest was 45 min (Hatayama et al.,2008). Hatayama et al. (2008) performed a 45-minute facial
massage on women in their 20s-40s. It included a steam andultrasound treatment. Suga et al. (2015) implemented a 3minute × 3-week face care session, in which elder women
applied lotion onto their skin; results indicated increased
parasympathetic nerve activity. As the intervention by Sugaet al. is similar to massage therapy, in that it involves touching the skin of the face for 3 min, we decided to perform
massage for 3 min, as the short duration would not burden
the participants or the researchers providing the massage. In
this way, the effectiveness of facial massage, performed invarious ways for women of various ages, has been investigated. We believe that recruiting healthy female college students as participants would control other confounding variables such as age, body size, life rhythm, and psychological
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stress (Bennion et al., 2018; Kubota et al., 2020).
The purpose of our study was to determine the physiological and psychological responses of healthy female college students to a 3-minute facial massage and to examine
whether facial massages can be used as a nursing technique
for stress relief. With the current study, we want to demonstrate that a 3-minute facial massage is, therefore, safe andeffective according to the physiological and psychologicalindicators and to establish it as a form of care that can be
implemented by nurses. We hope that nurses who have mastered this care technique will be assigned to each ward, orthat a nurse belonging to the palliative care team, for example, could go to the ward nurses when they request her todo so and systematically engage with patients.

Materials and Methods
Study Design
We wanted to examine the effects of facial massage fromboth physiological and psychological aspects while controlling for other conditions as far as possible. Therefore, we recruited female students, over 20 years old, enrolled in thenursing department of the author’s university. As we planned
to recruit female university students, the number of students
willing to participate was expected to be lesser than desired
due to academic schedules and other factors; moreover, it
was unlikely that the number of participants would increase
post recruitment; therefore, we adopted a crossover design.
Each participant received two interventions in our crossoverdesign―a 3-minute face massage and a 3-minute rest―indifferent sequences. An advantage of the crossover design isthat sufficient statistical power can be attained even withfew participants. However, one of its drawbacks is that a
carry-over effect can occur. Thus, it is necessary to include awashout period to eliminate the carry-over effect. The lengthof the washout period depends on the type of treatment;
however, 1-2 weeks for single inoculations is suggested(Origasa, 2016). Previous studies on massage and nursing
care have also indicated a 1-week washout period (Edwards
et al., 2018; Groven et al., 2021; Miyoshi, 2019). The influence of the “carry-over effect” is expected to be eliminatedduring this period. In the current study, as the facial massage was a one-time intervention and its effects could not belong-term, a 1-week washout period was considered sufficient. As mentioned above, this study is exploratory, as thenumber of participants was not calculated, and was determined by referring to previous studies, wherein the numberof participants ranged from 6 to 12 (Tsubouchi et al., 2010;
Ejindu, 2007; Sakai et al., 2012).
The study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the Institutional
Review Board of [name blinded for review] Nursing Science
Ethics Committee (approval number D13-06, November

https://doi.org/10.53044/jinr.2021-0005

2015). The Clinical Trial Registration number is [Trial registration number deleted to maintain the integrity of the review process].
Participants
During April 2018, when students stayed relatively on campus, we put up posters in classrooms at the University of[name blinded for review] to recruit participants. We selected nursing students who belong to the same university as
the researcher for the following two reasons. There are few
intervention studies using facial massage, and it was notpossible to understand the progress of the subjects after theintervention based on these previous studies. Therefore, inthe present study, it was possible that the participants’ situation after the facial massage intervention may have requireda quick response. We were confident that the physical effects on the subjects in our study would be minimal because
the massage intervention was brief and did not involve theuse of harmful oils or equipment. However, we invited nursing students from the researcher’s university to participate in
the study, as we believed that the researcher would be able
to respond immediately in the unlikely event that any
changes were observed after the intervention. It was also expected that nursing students who agreed with the theme of“stress relief through facial massage” would participate proactively, and that there would be fewer missing responses tothe questionnaire and fewer dropouts during the study. Furthermore, it was expected that the nursing students would
understand the purpose of the study, which was not directly
beneficial to the participants, but would be beneficial to thepatients and would improve the quality of nursing care. We
valued the participants’ time and commitment, and we approached the study with the intention of making their participation meaningful.
During this period, the new university term had juststarted, and there were few events at the university. Therefore, although the sample size was small, the recruitment
was concluded within the planned period, especially considering the impact of changes in the participants’ environment
if the recruitment were to be extended. The study was conducted from May to June 2018. Participants underwent a sequence of “first intervention-7-day washout-second intervention” during the study period.
The participants were women over 20 years old, who had
no underlying or under-treatment illnesses. Participants withskin problems and allergic reactions to jojoba oil and who
were smokers were excluded. Similar to previous studies,
we did not recruit male participants due to a lack of clarification in the literature on physiological and psychologicalresponses due to sex differences. Additionally, if muscle
mass changes were identified due to differences in physique,resulting from sex differences, it may be difficult to unify
massage techniques.

JINR 2023, 2(1), e2021-0005

Since the participants were university students, it was explained that cooperation or non-cooperation in the researchwould not affect their academic performance. We explained
the participation period, interventions, and exclusion conditions and obtained written consent from the participants who
agreed to participate. The intervention allocation order was
created by another researcher, who was not involved in the
facial massage interventions. The study participants were assigned to two groups: a structured intervention followed bycontrol (Sequence 1) or control followed by the intervention(Sequence 2). A list of all participants was created, and arandom number, generated using Excel software, was placednext to each participant’s name. These random numbers are
generated within the range of 0-1. Participants with numbers
higher than or equal to 0.5 were assigned to Sequence 1,
and the rest were assigned to Sequence 2. The participants
were informed of their group assignment on the day of theexperiment. Participants followed that order, and no changes
were made. All participants were fully compliant with theresearch protocol and completed the entire research process.
There were no significant changes in the method after thecommencement of the study.
Intervention
The massage procedure employed was developed by the Japan Relaxation Care Association (JRC; https://www.npohomepage.go.jp). The purpose of this organization is to contribute to social welfare through the promotion of health andrelaxation care. The researchers in the present study weretrained in massage procedures by the JRC in 2010, they hadreceived their technical certificate, and their skills wereregularly assessed. Jojoba oil―primarily a moisturizing oilwith no warnings of toxicity or carcinogenicity―was used
for the massage (Habashy et al., 2005). We conducted apatch test to ensure no adverse effects on participants; noskin changes were noted.
The outline of the massage is as follows:
1．Apply oil to both cheeks and jaws
2．Massage (2 min, 20 s):
i. Effleurage of the parotid gland from the jaw
ii. Effleurage in front of the ears from the corners ofthe mouthiii. Effleurage of the temple area from the noseiv. Temple area effleurage,
v. Lifting from chin to cheekvi. Lifting from jaw to cheek
3．Touch pressure (40 s):
i. Margo supraorbitalis (nasal side) and infraorbitalis (median)ii. Under the cheekbones and middle of the jaw.
Experimental Protocol
The day before the experiment, participants were requested
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to avoid overeating, consuming too much alcohol and caffeine, staying up late, strenuous exercise, and wearing loosefitting clothes and rinse their mouths before entering thelaboratory. When the participants arrived at the laboratory,
they sat in chairs, and we asked them to relax. After fillingout the questionnaire, they rested on a bed for 10 min.
The participants were asked to respond to the Profile ofMood States (POMS) questionnaire and a Visual Analog
Scale (VAS) for relaxation, pleasantness, and arousal before
and after the experiment. Next, participants placed themselves in a supine position on the bed, and the cuff of an
automatic sphygmomanometer was wrapped around their
upper limb to measure BP and pulse. Saliva was collectedby placing a stick under the tongue, and salivary alphaamylase (sAA) was measured.
Next, a facial massage, consisting of effleurage and touchpressure, was performed for 3 min, as per the abovementioned procedure. For the control condition, the participants
rested on the bed for 3 min. At the end of the experiment,BP, pulse, and sAA levels were measured again. Finally,
they were asked to answer questions about their perceptionsof the experiment.
Experimental Environment
Data collection was conducted at the [name blinded for review] University School of Medicine, Department of Nursing, from April to June 2018 from 3:00 pm to 5:00 pm. The
laboratory environment was 23°C ± 2.2°C, relative humidity
54% ± 6.9%, and illuminance 323.2 ± 52.5 Lx. The same
bed was used for both the experimental and control conditions. Participants laid down on the bed and were covered
with a cotton blanket. The same researcher stood beside theparticipants in the control condition as well.
Outcomes
The primary outcome of the study was BP, as a physiological indicator; pulse and sAA were collected as indicators of
the two major stress response systems: the autonomic nervous system and the hypothalamic-pituitary-adrenal system.
BP and pulse were measured using an automatic sphygmomanometer (Digital Automatic Sphygmomanometer, HEM757). Saliva was collected to determine sAA levels, using a
dedicated chip and analyzer (Enzyme Analyzer/Saliva Amylase Monitor CM-21; Nakano and Yamaguchi, 2011). The
secondary outcome measures were psychological indicators,
as measured via the POMS questionnaire and VAS. The
POMS was developed by McNair for evaluating mood
(Maxwell, 1978) and has also been used in other studies toassess the effects of massages (Chaiyasut et al., 2020;
Nadal-Nicolás et al., 2020; Serfaty et al., 2012). It has beentranslated into Japanese (Yokoyama, 2008) and used inmany studies, and its reliability and validity have also been
established. An abbreviated version of the Japanese version
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of POMS (Yokoyama, 2008) was used to assess psychological state. This questionnaire consists of 30 items that areused to measure six moods and emotions (Tension-Anxiety,Depression-Dejection, Anger-Hostility, Vigor-Activity, Fatigue-Inertia, and Confusion-Bewilderment). The test asks
participants to describe their current feelings and is scoredon a five-point Likert scale ranging from 0 (Not at all) to 4
(Extremely). For POMS, we explained that although thequestionnaire asks the participants to report on their “moodof the past week,” for this experiment, the participants wereto report their “current mood.” We also explained that for
both the POMS and the VAS, the participants should answer
each question with their current first impression.
“Relaxation,” “Comfort,” and “Wakefulness” levels wereassessed using the VAS. The VAS (Kuhlmann et al., 2017)
was introduced as a clinical measurement method for assessing pain. In massage research, the degree of pain, comfort,and drowsiness before and after massages have been measured using the VAS (Buttagat et al., 2020; Cavdar et al.,2020; MacSween et al., 2018). It expresses the amount ofsensation through the length of a line segment, and usually,
adjectives such as “nothing” and “maximum” are attached toboth ends of a 10-centimeter line. The respondents were required to mark their sensations, feelings, and experiences ona line segment before the intervention, post which experience and changes were recorded, based on the participant’s
subjective understanding.
Statistical Analysis
First, participants were assigned to Sequence 1 and Sequence 2 using a random function, and a two-sample t-test
was conducted for each of the demographic characteristics.
When employing a crossover study, a washout period is necessary to avoid carry-over effects (Origasa, 2016). In thepresent study, the intervention lasted for 3 min; therefore,
the long-term effects on the body were considered to be
negligible. Therefore, we can assume that there would be nocarry-over effect after providing a 1-week washout period.
However, to verify the validity of the study, the amount ofchange in each variable before and after the intervention
was analyzed through repeated-measures analysis of variance (ANOVA). To verify the treatment effect, the change ineach item was tested by a two-sample t-test. Statistical significance was set at p < .05. SPSS ver.21 was used for data
analysis.

Results
Participant Numbers and Characteristics
Of the 55 potential participants, 23 were enrolled in thetrial, but 32 did not register, for example, because they
could not participate in the two experiments at the sametime zone.

https://doi.org/10.53044/jinr.2021-0005

JINR 2023, 2(1), e2021-0005

Assessed for
eligibility (n = 55)

Excluded (n = 33)
・Not meeting inclusion criteria (n = 0)・Declined to participate (n = 32)
・Other reasons (skin trouble) (n = 1)

Random allocation (n = 22)

Period I

Sequence1

Sequence2

A/B (n = 11)

B/A (n = 11)

A: (n = 11)

B: (n = 11)

Measurement

MeasurementĻĻ

Received allocatedReceived allocated“facial massage” (3min)“rest in bed” (3min)ĻĻ

Measurement

Measurement

Washout period (7 days)

Period II

B: (n = 11)

A: (n = 11)

Measurement

MeasurementĻĻ

Received allocatedReceived allocated“rest in bed” (3min)“facial massage” (3min)ĻĻ

Measurement

Measurement

Analysis

Figure 1. Flow diagram of participants.

In addition, one participant was excluded as we noted
acne and redness of the skin. Therefore, 22 individuals eventually participated in the study (Figure 1). The 22 participants were randomly divided into two groups. The difference between the two groups at baseline before the experiment was not statistically significant (Table 1). None of theparticipants dropped out of the study or complained ofchanges in their physical condition post participation.
As we analyzed each variable’s change before and after
the intervention using repeated-measures ANOVA, there wasno carry-over effect or period effect due to crossover testing.
In the treatment effect, systolic BP was F = 5.132, p = .035;
diastolic BP was F = 5.210, p = .034; relax level was F =23.43, p = .000; and comfort level was F = 13.52, p =.0030. To verify the treatment effect, the amount of change
in each item was tested by a two-sample t-test. As this is an
exploratory study, p-values were set without considering
multiplicity.
The results of physiological measurements are shown in
Table 2. The amount of change in systolic BP was 0.72 (SD
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https://doi.org/10.53044/jinr.2021-0005

Table 1. Characteristics of participants (n = 22).
Mean (SD)
Variables
Sequence 1 (n = 11)

Sequence 2 (n = 11)p

20.7 (1.1)
19.5 (1.4)
99.5 (8.7)
58.0 (5.5)
69.6 (5.4)
52.4 (24.1)

20.6 (0.6)
21.8 (2.9)
107.6 (12.7)
63.8 (7.2)
74.1 (13.3)
48.1 (24.5)

.84
.08
.84
.44
.65
.50

Age (years)
Body Mass Index
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Pulse (bpm)
Salivary α-amylase (kIU/l)

Notes: Data are measurements after allocation to Sequence 1 and Sequence 2.
p-values of two-sample t-test. *p<.05.

Table 2. Comparison of the amount of change in physiological measures (n = 22).
Mean (SD)
Variable
Systolic BP (mmHg)
Diastolic BP (mmHg)
Pulse rate (bpm)
Salivary α-amylase activity (kIU/l)

Facial massage (n = 22)

Control (n = 22)0.72 (5.46)
1.81 (4.61)−4.50 (5.60)−11.77 (21.22)−2.36 (4.49)−0.77 (4.78)−3.22 (4.47)−13.80 (22.57)

t

p

ES
(r)

95% CI

2.05
1.82
−0.83
0.28

.047*
.075
.410
.778

0.30
0.27
0.13
0.05

[0.05, 6.13][−0.27, 5.44][−4.35, 1.81][−12.43, 16.48]

Notes: t- and p-values of two-sample t-test. *p<.05.
Abbreviations: BP, blood pressure; ES, effect size.

5.46) in the facial massage group and −2.36 (SD 4.49) inthe control group, with significantly higher change in the facial massage group (t = 2.049, p = .047, r = 0.30). The actual measurements were: pre = 102.4 (SD 9.8) mmHg, post
= 103.1 (SD 9.3) mmHg in the facial massage group andpre = 102.7 (SD 12.1) mmHg, post = 101.0 (SD 10.7)mmHg in the control group. The amount of change in diastolic BP was 1.81 (SD 4.61) in the facial massage groupand −0.77 (SD 4.78) in the control group, with no significant difference between the two groups (t = 1.82, p = .075,
r = 0.27). The amount of change in pulse was −4.50 (SD5.60) in the facial massage group and −3.22 (SD 4.47) inthe control group, with no significant difference between thetwo (t = −0.83, p = .410, r = 0.13). The change in sAA was−11.77 (SD 21.2) in the facial massage group and −13.80(SD 22.5) in the control group, with no significant difference between the two (t = 0.28, p = .778, r = 0.05).
The results of psychological measurements are shown in
Table 3. In the six domains of POMS, there was no significant difference in the amount of change before and after theintervention in both groups. The amount of change in the“Relaxation level,” as measured by VAS, was 2.26 (SD1.56) in the facial massage group and 0.32 (SD 2.11) in thecontrol group, with significantly higher scores in the facial
massage group (t = 3.39, p = .002, r = 0.47). The amount ofchange in the “Comfort level” was 1.48 (SD 1.4) in the facial massage group and −0.11 (SD 1.75) in the control
6 of 12group, with significantly higher scores in the facial massage
group (t = 3.21, p = .003, r = 0.45). The amount of change
in the “Wakefulness level” was −1.12 (SD 3.2) in the facial
massage group and −2.10 (SD 2.01) in the control group,and there was no significant difference between the two (t =1.19, p = .241, r = 0.19).
Participant’s Feedback
In the facial massage group, statements such as “I felt wakeful after the facial massage,” “I thought it might be beautiful,” and “I felt refreshed” were more frequently reported. In
the control group, comments such as “I became sleepy,” “I
was bored,” and “Nothing in particular” were reported. In
the facial massage group, mood changes were described,
and in the control group, drowsiness during rest was described.

Discussion
This study aimed to determine the physiological and psychological effects of a facial massage on healthy female college students. While BP was the primary outcome, as ameasure of stress relief, other physiological and psychological responses were the secondary variables, used to evaluate
the effects of a 3-minute face massage compared to the 3minute rest group.
Regarding BP, the primary outcome variable, previous

https://doi.org/10.53044/jinr.2021-0005

JINR 2023, 2(1), e2021-0005

Table 3. Comparison of the amount of change in psychological measures (n = 22).
Mean (SD)
Variable

t

p

ES
(r)

95% CI

Facial massage (n = 22)

Control (n = 22)−5.31 (7.37)−1.54 (3.40)−3.27 (6.71)−1.18 (8.02)−4.00 (6.73)−1.22 (5.37)−2.63 (3.52)−2.09 (4.41)−1.77 (3.75)−4.13 (4.80)−1.72 (5.53)−1.50 (4.31)

−1.53
0.45
−0.91
1.48
−1.22
0.18

.131
.649
.366
.146
.228
.854

0.23
0.07
0.14
0.22
0.19
0.03

[−6.19, 0.83][−1.85, 2.94][−4.80, 1.80][−1.07, 6.97][−6.02, 1.47][−2.69, 3.23]

2.26 (1.56)
1.48 (1.48)−1.12 (3.22)

0.32 (2.11)−0.11 (1.75)−2.10 (2.01)

3.39
3.21
1.19

.002*
.003*
.241

0.47
0.45
0.19

[0.78, 3.08][0.59, 2.59][−0.68, 2.64]

POMS
Tension–Anxiety
Depression–Dejection
Anger–Hostility
Vigor
Fatigue
Confusion
VAS
Relaxation level
Comfort level
Wakefulness level

Notes: t- and p-values of two-sample t-test. *p<.05.
Abbreviations: POMS, Profile of Mood Scale; VAS, Visual Analog Scale; ES, Effect Size.

Table 4. Participant’s feedback.
Facial massage

Control• I got sleepy during the massage. Afterwards, when I opened myeyes, I felt like I was awake.

• Just from resting, I got a bit slow and gradually became sleepy.
• I fell asleep during the experiment.
• I got sleepy gradually when I was daydreaming for a few minutes.
• I felt a bit lonely.
• I was bored.
• Nothing in particular.

• I got sleepy, but after the facial massage, I felt refreshed.
• I expected that receiving a facial massage would result in beauty
enhancement.
• I would like to receive a facial massage as an aesthetic agent.
• I thought it might be beautiful.
• It was good!
• The massage was relaxing.
• I closed my eyes during the facial massage, then my hands felt
warm and I felt calmer.
• The facial massage provided a sense of ease.
• The massage ended quickly. I hope it’s a little longer.

studies have reported a decrease in BP post massage (Liaoet al., 2016; Givi et al., 2018; Moraska et al., 2008). In thecurrent study, systolic BP increased in the facial massage
group, but the amount of change in both groups was small
and not a clinically significant value. Thus, there was almost
no change in BP in both groups compared to previous reports, possibly due to participant characteristics and the timeand frequency of facial massage. This study targeted healthy
female college students; however, many previous studies
have targeted individuals with hypertension or hypertension
reserves, or individuals with anxiety or pain, and slightly
high baseline BP (Liao et al., 2016; Givi et al., 2018; Moraska et al., 2008). These participants were given multiple
stress-relieving massages over a medium to long term. Liaoet al. (2016) gave eight women with hypertension (or reserves) a weekly, 1-hour, full-body Swedish massage for 4

weeks, leading to a sustained reduction in systolic BP until
4 weeks later. In a study by Givi et al. (2018), 25 womenwith prehypertension were massaged for 15 min, three times
a week for 10 sessions; their BP, as measured 72 h after themassage, was significantly lower than that of the control
group. Two weeks after the end of the massage, the decrease
in BP was no longer observed. This clarifies the period after
which the effect of massage dissipates and indicates the necessity of repeating massages at appropriate intervals, formaintaining the decrease in BP due to massage. Thus, while
previous studies report a decrease in BP after continuous
massage, a similar decrease was unlikely to occur with only
one massage conducted in this study. Moreover, the massage
time of 3 min employed in the current study can be considered a factor affecting the lack of decrease in BP. According
to a study by Sato et al. (2007), a massage-like stimulus ad7 of 12

JINR 2023, 2(1), e2021-0005

ministered to the abdomen of rats for 5 min reduced BP by
up to 20 mmHg; however, this decrease was dampened in a
2-minute stimulus, which soon reached the original levels.
Other studies have reported that the decrease in BP is further sustained by the secretion of oxytocin when the skin is
stimulated by massage for 5 min or longer (Araki et al.,
1984; Sato et al., 2007). Therefore, it is possible that the 3minute face massage employed in the present study did nothave a physiological effect and, thus, did not reduce BP.
It was also considered that participants’ stress level was
related to the change in BP. In the present study, the baseline value of α-amylase in saliva, which is an index ofstress, indicated mild stress; however, there was almost nochange post intervention. Sripongngam et al. (2015) performed Thai Traditional Massage after introducing a 10minute mental arithmetic test to participants whose stresslevels were mild as assessed by the Suanprung Stress Test20, before the intervention. Participants’ stress level decreased, as indicated by a decrease in sAA and an increasein the high frequency component of heart rate variability(HRV). Thus, application of massage during a certain
amount of mental stress can predominate parasympathetic
nerve activity and induce a stress-relieving response. Moreover, although participants in the present study are thought
to have stress peculiar to university students (Kubota et al.,2020), but due to the low levels of stress, no autonomic
nervous system changes occurred after 3 min of stimulation
with facial massage. Therefore, the facial massage did not
trigger a nervous system response, and thus, the BP did notshow a decrease.
We also wondered if the psychological response of massaging the face affected changes in BP, possibly due to thepeculiarity of facial massage. Generally, the face is a bodypart rarely touched by others. Therefore, we believe thatsuch an experience of someone touching one’s face might
have induced tension in some participants. Participants also
reported different expectations from the massage, such as “I
expected a beauty effect by receiving a facial massage” and“I thought it might be beautiful.” Thus, such psychologicaltension could have affected the lack of pulse rate change
noted in this study. Hatayama et al. (2008) found that HRV
significantly increases sympathetic nervous system activity
after a facial massage, although no such changes were observed in pulse rate. The authors asserted that facial massage
has a refreshing effect and activates sympathetic nerve activity (Hatayama et al., 2008). Furthermore, in this study, participants reported experiences such as feeling “refreshed”
and “feeling awake”; thus, we suppose that the enhanced
mood acted on the sympathetic nerves and it did not reducethe BP or pulse (Meier et al., 2020). In other words, we
speculate that the emotional response of massage was regulated by the limbic system, which is closely related to theautonomic nervous system, and affected sympathetic nerve
8 of 12https://doi.org/10.53044/jinr.2021-0005

activity (Aourell et al., 2005). Although a study of makeup
behavior rather than facial massage, Watanabe (2013) compared emotional responses in the makeup behavior groupand the control group by VAS and found that the scores are
significantly higher after the make-up action, especially forthe items “feel comfortable,” “gets energized,” “vibrant,”“enchanted,” and “enjoyed.” Therefore, stimulating the face
may bring about a feeling of tension or mood upliftment,
engaging in predominantly sympathetic nerve activity, which
may slightly increase BP rather than decrease it. Therefore,
we suppose that massaging only the face, as in this study,
activates the sympathetic nervous system rather than theparasympathetic nervous system.
As a secondary outcome, we also measured “moodchange” using the POMS questionnaire and “Relaxation,”“Comfort,” and “Wakefulness” levels using the VAS. Results
indicated that POMS score was not different between thetwo groups, but “Relaxation” and “Comfort” levels measured by the VAS were significantly increased in the facial
massage group. In previous studies, “mood and emotionalchanges” indicated through POMS and VAS have often
shown similar trends. As there were few studies on facemassage, we examined studies that have tried to relievestress by massaging the head. Shimada et al. (2013) measured stress relief by scalp massage using POMS and VAS.
Before and after scalp massages, POMS scores were lesser
for negative emotional items, and VAS scores indicated reduced physical fatigue. An increase in the degree of relaxation was observed, and scores of both POMS and VAS
agreed. In addition, salivary cortisol concentration, which indicates the degree of stress, decreased, and secretory immunoglobulin A concentration significantly increased, thus suggesting that psychological and physiological changes wereconsistent. Murota et al. (2016) performed head massage using an Ayurveda-based technique to reduce diastolic BP andincrease the high-frequency component of HRV and “Liveliness,” as measured by VAS. Results revealed a decrease in“depression” and scores of the State-Trait Anxiety Inventory.
Thus, previous studies have reported agreement in physiological and psychological changes caused by massage.
Moreover, to the best of our knowledge, no study reported
different tendencies for the two psychological indicators, as
observed in this study. The research design could be one of
the factors that might have influenced this finding in ourstudy. In the current study, we limited the participants tohealthy female college students, so that their age, gender,
daily living environment, etc. could be controlled; therefore,
we recruited participants and conducted the study at the university to which the researchers belong. Consequently, theparticipants and researchers were acquainted with eachother, and we suspect that some psychological bias, possibly
the Hawthorne effect, occurred for the participants. The
Hawthorne effect explains participants’ psychological factors

https://doi.org/10.53044/jinr.2021-0005

that influence the outcome of nursing research interventions(Tagaya, 2014). The Hawthorne effect may occur on the partof the participants, wherein they may be “over-adapted”(Tasaki and Shin, 2017) to meet the expectations of theevaluator/observer and give a better response than their actual experience. VAS scores are indicated on a 10-centimeter
horizontal line, and there is a possibility that a value close
to the positive end (10 cm) will be indicated (Tasaki andShin, 2017). On the other hand, in the case of POMS, 30
questions are answered intuitively in 5 steps; thus, there is apossibility of taking an “acquiescence response style” thatagrees without thoroughly examining the content (Tasaki
and Shin, 2017). In this way, when examining the effects ofperson-to-person intervention, as in the current study, results
may be affected by psychological factors depending on therelationship between the participant and the researcher.
Careful selection of study designs and methods, such as the
adoption of randomized controlled trials and the adoption of
appropriate physiological and psychological indicators, is required to mitigate this effect. The abovementioned researchon head massage by Murota et al. (2016) was also conducted with female university students; however, the massage was performed by a therapist rather than the researcher
to avoid the Hawthorne effect. Resultantly, the changes inphysiological and psychological indicators agreed, and thus,
the reliability of the data increased. In our future research,
we shall endeavor to eliminate such feelings of pressure forparticipants.
In sum, this study did not indicate a decrease in BP or
stress relief due to a 3-minute facial massage in healthy female college students. However, it is possible to induce
positive emotions by massaging the face, and psychologicalchanges can lead to physiological responses (Meier et al.,2020). Furthermore, to apply it as a nursing technique, it isnecessary to consider the stress level of the subject, their
feelings toward facial massage, the time and frequency of
massage, and the implementation period.
In this study, participants were healthy female university
students. Thus, the results obtained in this study could be
used as the basis to explore these variables with diverse participant populations further and to conduct large-scale confirmation studies. Moreover, we recommended collecting
data independently in the intervention and control groups.
Furthermore, there may be differences in interest in facial
massage between men and women. For example, in a previous study of facial massage (Ejindu, 2007), when recruiting
participants, only one man offered to participate in the
study. Thus, future studies should investigate the physicaland psychological reactions of men during facial massage.
Further, in the present study, as the facial massage was performed only once and for short period, it is likely that theeffect was not fully exerted. Therefore, we would like tofurther investigate the stress-relieving effects of facial mas-

JINR 2023, 2(1), e2021-0005

sage and techniques that caregivers can easily and continuously employ at nursing facilities and hospitals.
Conclusion
BP increased slightly after the facial massage, but theamount of change was similar to that of the control group.
The amount of change in pulse and sAA was also the sameas in the control group. With respect to psychological measures, POMS did not differ between the two groups; however, “Relaxation” and “Comfort” levels as measured by
VAS increased significantly with facial massage. Facial massage had a positive effect on some psychological indices,
but changes in physiological indices, such as BP, could not
explain the stress relief.
Acknowledgments
We would like to thank JSPS KAKENHI (Grant Number:
JP24593201) for supporting this research. We would like tothank the participants for their cooperation in our study. I
am very grateful to Makiyo Nakano, the director of the Japan Relaxation Care Association.
Author Contributions
All authors have approved the final article and acknowledge
that all those entitled to authorship are listed as authors. All
authors met the criteria of authorship, substantial contributions to (1) conception and design, acquisition of data, or
analysis and interpretation of data; (2) drafting the article orrevising it critically for important intellectual content; and(3) approval of the final manuscript. Yuriko Ohkawa (YO),
Hiroki Tanoue (HT), and Kiyoko Fukai (KF) especially contributed to the study design, coordinated the study, interpreted the data, and drafted and reviewed the manuscript.
YO especially contributed to the collection of data and theperformance of statistical analyses. YO and HT especiallycontributed to program development and the supervision ofprogram implementation.
Declaration of Conflicting Interests
The authors declare that they have no conflict of interest.
Disclaimer
KF is an Editorial Adviser of Journal of International Nursing Research and on the journal’s Editorial Committee. She
was not involved in the editorial evaluation or decision toaccept this article for publication at all.
Ethical Approval
The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Institutional
Review Board of the Okayama University Graduate School
Nursing Science Ethics Committee (approval number: D1306, November 2015).
9 of 12JINR 2023, 2(1), e2021-0005

Funding
This work was supported by JSPS KAKENHI (Grant Number: JP24593201).
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https://doi.org/10.53044/jinr.2021-0016
https://www.jinr.jsnr.or.jp/

Original Research

Proficiency evaluation of simulation education on the entire tracheal
suctioning process using a motion capture system and a catheter control
sensing device
Noriyo Colley, EdD, RN1 , Shunsuke Komizunai, PhD2 , Satoshi Kanai, PhD2 , Atsushi Konno, PhD2 ,Sozo Inoue, PhD3 , Misuzu Nakamura, PhD, RN4 , and Shinji Ninomiya, PhD5
1

Faculty of Health Sciences, Hokkaido University, Sapporo, Japan, 2Faculty of Information Science andTechnology, Hokkaido University, Sapporo, Japan, 3Graduate School of Life Science and Systems Engineering,
Kyushu Institute of Technology, Kitakyusyu, Japan, 4Graduate School of Nursing, The Jikei University, Tokyo,
Japan, and 5Department of Clinical Engineering, Hiroshima International University, Hiroshima, Japan

Abstract
Objective: We developed a suctioning catheter control sensing device given the increasing demand for skilled
home-based healthcare techniques, such as tracheal suctioning. This study evaluated the proficiency of the entire
tracheal suctioning process between expert and novice groups via the suctioning catheter control sensing device
and a motion capture system. Our hypothesis is that motion capture can measure the proficiency of tracheal suctioning despite the biological reactions of the simulator and the characteristics of participants. Methods: Nine expert nurses, each with more than three years of clinical experience in tracheal suctioning, and 13 nursing students
from an urban university nursing department participated. The performance time, pelvic forward bending angle,
travel distance, posing time, posing frequency of bilateral dorsum manus, and suctioning catheter control between
the two groups with/without simulated biological reactions were analyzed. Results: The two-way analysis of variance demonstrated that the biological reactions (or lack thereof) and the proficiency level did not interact. The
main effect of performance time, posing time, and posing frequency was statistically significant; experts performed
tracheal suctioning more expeditiously and skillfully. The sensing device could detect hesitance or rough catheter
control. Conclusions: Our results indicated that performance time, posing time, and posing frequency could serve
as proficiency criteria with/out biological reactions. Additional studies are required to establish a quantitative education evaluation method to determine clinically reliable proficiency levels of tracheal suctioning.
Keywords
projection mapping, biological reactions, skill evaluation, nursing education, VR/AR/MR/XR
JINR 2023, 2(1), e2021-0016

Introduction
The number of children (0-19 years old) requiring
technology-dependent, specific home-based healthcare techniques, such as tracheal suctioning, tracheostomy, and percutaneous endoscopic gastrostomy, has doubled from 8,438 in2007 to 19,712 in 2017 in Japan despite vast improvementsin the survival rates of premature infants (Ministry of
Health, Labour and Welfare, 2020). An analogous trend was
also observed internationally (Breneol et al., 2019; Choi etal., 2020). The demand for registered community nurses isincreasing to provide technical advice to family caregivers in

Correspondence: N. Colley. Email: noriyo@med.hokudai.ac.jp
Received: August 27, 2021, Accepted: February 18, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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addition to the employment of hygienic, accurate, and comfortable healthcare techniques (Nageswaran et al., 2017;
Sobotka et al., 2019; Choi et al., 2020; Colley et al., 2020a;
Whalen et al., 2020).
Tracheal suctioning is an invasive nursing technique that
requires adequate knowledge, appropriate clinical judgment
skills (Kim et al., 2016), and adequate mastery to prevent
unexpected adverse events, such as hypoxia, alveolar collapse, cardiac arrhythmia, blood pressure changes, raised intracranial pressure, and ventilator-associated pneumonia(Schults, 2021). Subject to these biologically invasive characteristics, objective skill evaluation criteria that can be used
as indices to quantify the level of mastery are necessary(Nishiyama, 2016; Garner et al., 2020). There are two mainstreams in conventional pedagogical evaluation in nursing:technical observation by instructors and/or judgment of selfefficacy among students (Garner et al., 2020). However,these evaluation methods cannot entirely exclude the subjective influences of instructors and/or learners. Zughoul et al.
surveyed existing studies on pedagogical evaluation among
various academic domains, including nursing education.
They reported that assessment criteria are necessary to quantify student capability, learning outcome, performance,
knowledge, and skills (Zughoul et al., 2018).
Recently, motion capture has been used extensively as anursing research methodology to facilitate visualization of
the joint motion of dominant and nondominant upper limbs
for operations, such as opening ampoules (Hirano et al.,2019), transfer of patients with occupational lower-back painfrom a bed to a wheelchair (Nakagawa et al., 2017; Lin,
2018; Zhou et al., 2021), and ultrasound-guided peripheral
intravenous catheter placement (Good et al., 2018). Quantitative parameters, such as performance time, path length, velocity, and acceleration, have been gradually adopted as
rigid evaluation criteria for these clinical skills (Zago et al.,2020). Further, several studies have attempted to determine
the relationship between suctioning catheter control and tracheal secretion viscosity and concluded that greater sidehole diameter, nonparallel positioning, and the duration ofsuctioning affect the effectiveness (Shah et al., 2005; Colley
et al., 2020b). However, there has been no consensus regarding standardized parameters to assess skill acquisition in thecase of tracheal suctioning. There also exists limited evidence on the quantification of proficiency during the entire
process of tracheal suctioning.
Therefore, in this study, we aim to compare the skill proficiency over the entire process of tracheal suctioning between expert and novice groups via a motion capture system
and a catheter control sensing device developed by us. Our
hypothesis is that motion capture can measure the proficiency of tracheal suctioning despite the biological reactionsof the simulator and the participants’ characteristics.
2 of 11https://doi.org/10.53044/jinr.2021-0016

Materials and Methods
Tracheal Suctioning Simulator
Tracheal suctioning is an airway management techniqueused to maintain the natural or artificial airway patency byremoving sputum with a thin suctioning tube. This isachieved by applying negative pressure, which requires hygienic handling by the dominant hand, gentle manipulationof the suctioning catheter, and shorter application of negative pressure in the airway (Pasrija & Hall, 2021). Researchers have developed a tracheal suctioning simulator called theendotracheal suctioning training environment simulator(ESTE-SIM). It comprises an artificial trachea membranemodel with load sensors (Colley et al., 2016; Ninomiya etal., 2017; Hayashi et al., 2018; Ninomiya et al., 2018; Ninomiya et al., 2019), a patient upper body manikin, a projector
for facial expression generation (Fauzi et al., 2019a; Fauzi etal., 2019b), an android tablet for simulated pulse-oximeterreadings (Colley et al., 2018; Komizunai et al., 2018), and acontrol personal computer (PC). The artificial trachea membrane model with load sensors, namely the ESTE sensing
device (ESTE-SD), can measure the contact force and insertion depth of the suctioning catheter tip inserted in the tracheal tube with the use of the load sensors attached to theartificial trachea membrane model. The data from the ESTESD are sent to the control PC, which generates the facial expression on the patient upper body manikin via projection
mapping (Komizunai et al., 2019).
In this study, a cough sound function generates sounds 10
s later after removing an airway filter. The simulated pulseoximeter values, from pulse oximetry data during tracheal
suctioning in our previous study (Komizunai et al., 2019),
were implemented in addition to facial expression changes,
as shown in Figure 1. Herein, the term, biological reactions(BRs), is used for these reactions as an umbrella term.
ESTE-SD
Figure 2 shows the schematic of the ESTE-SD depicting theforce along the superior-inferior direction (Fx), momentum
force along the left-right direction (My), and the force along
the head-tail direction (z-axis). The three functions of
ESTE-SD include the estimation of the inserted length of asuctioning catheter using the measured forces Fx and My,
the sensing force on the artificial tracheal membrane, andweighing of the suctioned artificial phlegm.
Participants
The required sample size was calculated using the software
G*Power (Version 3.1.9.2, Institute for Digital Research &Education, California, Los Angeles, USA) a priori. We recruited 10 participants per group, which led to a power of
95% with an effect size of 0.25 for detection between
groups (α = 0.05). A total of nine expert nurses, each withhttps://doi.org/10.53044/jinr.2021-0016

JINR 2023, 2(1), e2021-0016

Synthetic image of facial expression
LCD Projector

Control PC
・Facial expression generation
by mesh deformation

Projected facial image

Suctioning tube
RelaxedSimulated pulse-oximeter
Tracheal tube

Artificial trachea model
Artificial mucus

Head mannequin

Painfulwith Cough soundPain intensity estimation

Load sensor
Sensor controller
・Tube contact force
・Tube insertion depth

FlatbedFigure 1. Endotracheal suctioning training environment simulator (ESTE-SIM).

more than three years of clinical experience in tracheal suctioning, and 13 nursing students from the Department of
Nursing in an urban university participated in the study. The
recruitment of registered nurses was conducted through theinternet. The registered nurses were from five institutions
and had frequent opportunities to perform tracheal suctioning. The nursing students were in the third year of theirbachelor’s courses, and they had completed lectures on tracheal suctioning as part of the regular course before the experiment was conducted. None of them had any prior clinical experience. These students were recruited via poster announcements and convenient recruitment within the university. Exclusion criteria included left-handed participants because they may introduce differentiation along the travel distance, and five novice participants were excluded comparing
immature hygiene manipulation or different order of procedure. There is no significant difference in the average heightof novice groups before and after exclusion (159.38±3.92,
p> .05).
Before beginning the experiment, institutional review
board approval was obtained from the institution’s ethicalcommittee. In addition, all participants provided written consent forms (17-81-2). To ensure anonymity, numbers N1-N9
were used to represent the registered nurses, and numbers
S1-S13 were used to represent the nursing students. Table 1
lists the participants’ characteristics.
Motion Capture System
An inertial magnetic motion capture system (Perception
Neuron, Noitom, China) was selected to measure the motionof the study participants. This system comprises a series ofinertial measurement unit nodes referred to as “neurons” thatare integrated with a 3-axis gyroscope, 3-axis accelerometer,and 3-axis magnetometer to record body movements digitally, with a sampling rate of 60 Hz. A total of 18 neurons
were placed on the participants’ heads, bilateral shoulders,
upper backs, bilateral lower backs, bilateral upper arms, bilateral lower arms, bilateral dorsum manus (BDM), bilateral
upper thighs, bilateral lower thighs, and bilateral dorsum pedis.
Motion parameters, such as performance time, pelvic forward bending angle, travel distance of the BDM, and posing
time and posing frequency of the BDM, were calculated(Osanai et al., 2019; Colley et al., 2020c). Their parameters
were determined from observing nursing students’ tracheal
suctioning procedures. As the performance time, the posing
time, and the posing frequency increase, the waiting time ofpatients increases. The pelvic forward bending angle wasmeasured as higher values are considered to constitute ahigh risk of droplet infection. Considering that removing thesuctioning catheter from the trachea is associated with theslowest motion, the posing time was defined as 1 cm/s
(Osanai et al., 2019; Colley et al., 2020c). The obtained data
were analyzed using the Axis Neuron (Noitom, China) software.
Procedures
The participants were requested to perform the entire process of tracheal suctioning twice with the BRs and twice
without them. The entire process of tracheal suctioning is asfollows: disposable glove placement, the connection of thesuctioning catheter, wiping the catheter with alcohol wipes,
turning the suctioning machine on, vacuuming rinse water,
checking the negative pressure, removing the airway filter,
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a)b)

Figure 2. Three-dimensional (3D) schematic of the apparatus of ESTE-SD: a) drawing and b) 3D view.

Table 1. Background information for study’s participants.

Experts
Novices

Dominant hand
(Left:Right)

Gender(Male:Female)

HeightMean ± S.D. (cm)Clinical experience
Mean ± S.D. (years)

1:8
0:13

0:9
1:12

157.11 ± 6.78
159.62 ± 5.68

12.89 ± 6.72
0inserting the suctioning catheter, applying negative pressurefor 10 s, removing the suctioning catheter, putting the airway filter back, wiping the catheter by alcohol wipes, vacuuming rinse water, disconnecting the suctioning catheter,
turning the suctioning machine off, and disposing of the
gloves. Before the experiment, the three BRs of ESTE-SIM4 of 11which lead to changes in simulated pulse-oximeter readings,
cough sounds, and changes in facial expressions-were explained to each participant. A standing position that allowed
for the participants to lower and relax both their arms on
both sides of the trunk was set as the base posture. Following the signal from the researcher, the participants per-

https://doi.org/10.53044/jinr.2021-0016

Table 2.

JINR 2023, 2(1), e2021-0016

Summary of results.

Performance time [sec.]
Pelvic forward bending
angle [deg.]
Travel distance of left
BDM [m]Travel distance of right
BDM [m]Posing time of left BDM[sec.]
Posing time of right
BDM [sec.]
Posing frequency of left
BDM [times]
Posing frequency of right
BDM [times]

Without BRs
With BRs
Without BRs
With BRs
Without BRs
With BRs
Without BRs
With BRs
Without BRs
With BRs
Without BRs
With BRs
Without BRs
With BRs
Without BRs
With BRs

Experts
Mean ± S.D.

Novices
Mean ± S.D.

Interaction
p-value

Main effectp-value

F-valueη2

67.05 ± 14.06
69.08 ± 14.47
9.44 ± 5.44
10.72 ± 4.25
14.48 ± 2.77
14.58 ± 4.39
18.55 ± 3.32
18.97 ± 3.49
20.01 ± 11.47
21.21 ± 13.46
11.76 ± 6.27
11.10 ± 7.19
8.63 ± 3.24
7.88 ± 3.37
5.63 ± 2.39
4.75 ± 2.54

102.31 ± 24.54
97.97 ± 11.48
13.39 ± 8.56
14.55 ± 8.32
15.69 ± 3.33
14.07 ± 1.61
19.38 ± 4.47
17.71 ± 3.13
46.39 ± 20.04
47.08 ± 14.81
32.39 ± 10.46
33.86 ± 12.85
15.25 ± 6.38
13.13 ± 4.73
14.63 ± 4.50
12.63 ± 3.67

.62

.00

24.90

0.02

.98

.14

2.23

-

.48

.77

0.08

-

.44

.64

0.21

-

.96

.00

20.46

0.03

.75

.00

35.88

0.02

.70

.01

11.63

0.06

.66

.00

43.44

0.02

formed the entire process of tracheal suctioning, from thefirst step, which involved glove placement, to the final step,which involved glove removal. The movement measurement
started once the base posture was assumed and stopped
when the participants reverted to the base posture at the end.
The height of the bed and the positions of the equipment
were kept constant.
Statistical Analysis
Variables were tested for normality based on the assessmentof the data distribution on a histogram. Motion parameterdata were tested with a two-way mixed analysis of variance(ANOVA) for the evaluation of the main effects of the twodifferent proficiency groups with/without BRs and their interaction. The significance level was p < .05. Sidak’s post
hoc tests were used for effect analysis. Microsoft Excel
2016 and MATLAB 2014a were used for analyzing data.

Results
Valid datasets for eight nurses and eight students were carefully selected from the two sets of trials. The performancetime, pelvic forward bending angle, travel distance of theBDM, posing time and posing frequency of the BDM fromthe perception neuron, and information on suctioning catheter control from the ESTE-SD were analyzed with/without
the simulated BRs.
Body Motion Detected by Motion Capture System
Table 2 summarizes the results of the two-way mixed
ANOVA. No statistically significant interactions appeared
between the two proficiency groups and the presence/ab-

sence of BRs. There were no main effects of the presence/
absence of BRs in performance time, pelvic forward bending angle, travel distance of the left BDM, travel distance ofright BDM, posing time of left BDM, posing time of right
BDM, posing frequency of left BDM, and posing frequencyof right BDM (p = .86, .62, .53, .87, .42, .27, .87, and .90,
respectively). However, the main effect of the performancetime [s] yielded F(1, 28) = 24.895, p < .01, η2 ＝ 0.024; aposing time of the left BDM [s], F(1, 28) = 5457.513, p< .01, η2 ＝ 0.030; a posing time of the right BDM [s], F(1,28) = 3747.615, p < .01, η2 ＝ 0.020; a posing frequency ofthe left BDM [count], F(1, 28) = 11.628, p < .01, η2 ＝0.062; and a posing frequency of the right BDM [count], F(1, 28) = 43.437, p < .01, η2 ＝ 0.017 between the twogroups. This indicates the existence of significant differenceswith small effect sizes in the performance time, a posing
time of the left and right BDM, and a posing frequency of
the right BDM between the expert and novice groups. A
middle effect size appeared in the posing frequency of theleft BDM (η2 > 0.06), which implies that the proficiency
difference in the posing frequency of the left BDM is larger
than that of the right BDM. The pelvic forward bending angle and travel distance of the BDM did not contribute significantly to proficiency.
Figure 3 shows the scatterplot of the performance time forthe two groups with/without BRs. By comparing the resultsof the two groups, we found that the expert group required aperformance time that was approximately 34.5% smaller
than that of the novice group despite the presence of simulated BRs. We estimated that the novice group would require a longer performance time in the trials without theBRs, yet there were no main effects between the BRs and5 of 11JINR 2023, 2(1), e2021-0016

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Performance time[s]

Pelvic forward bending angle

[°]
35

200

With BR

With BR

180

30

160

y = 0.4066x + 56.363

140

y = 0.7183x + 2.9377

25

R2 = 0.7556

120

R2 = 0.4875

20

100

15

80
60

10

y = 0.8962x + 8.9825

40
20

Without BR0050
Experts100

150
Novicesy = 0.6346x + 2.6331

5

R2 = 0.8179

R2 = 0.2458

Without BR

0
200

0

10
Experts

[s]

20

30
Novices40[°]

Figure 3. Comparison of performance time.

Figure 4. Comparison of pelvic forward bending angle.

the no-BRs of the student group.
The comparison of the pelvic forward bending angle isshown in Figure 4. Although several individuals tended totilt their upper body forward during tracheal suctioning, nomain effects were apparent based on the result of the twoway ANOVA. However, such a tilting posture on the tracheal tube can increase the risks of droplet infection, andproper instruction will be required for these individuals.
Three typical patterns of the travel distance of BDM arepresented in Figure 5, namely, right predominance, equal
pattern, and left predominance. There were no interactions
and primary effects between the different proficiency groups
and the presence of BR from the results of the two-way
ANOVA; however, these three patterns indicate that it ispossible to detect inefficient movements of the dominanthand. Considering that all participants were right-handed,
the travel distance of the BDM divided by the performancetime could be applied to evaluate proficiency.
Figure 6 compares the performance time and posing timeof the BDM with/without BRs. In the case in which no BRs
occurred, the posing time percentages within the performance time in the experts’ left and right BDM were 29.8%
and 17.5%, respectively. In the case in which BRs occurred,
the percentages of posing time within the performance timein the experts’ left BDM and right BDM were 30.7% and14.9%, respectively. For the novice group, the percentagesof posing time within the performance time increased inboth the BDM with/without BRs. The left and right BDMof the novice group without BRs were 46.6% and 29.7%,
respectively; they slightly increased to 50.0% and 31.1%
with BRs. Table 2 indicates that the development in the skill
proficiency between experts and novices is 34-44% smaller

than that in the posing time in the expert group.
The posing frequency of the BDM is shown in Figure 7.
The two-way ANOVA results indicate that there is no statistical significance with/without BRs, and there is entrainmentof the posing frequency in the left and right BDM. However, the main effect is detected between the expert and novice groups. Thus, experts performed tracheal suctioning witha statistically lower posing frequency despite the presence of
the BRs, which could be considered a criterion for proficiency evaluation.

6 of 11Catheter Movement Detected by ESTE-SD
The typical result from the ESTE-SD is shown in Figure 8.
The numbers in brackets indicate the amount of phlegm suctioned. The suctioning catheter movements of N4, S3, andS6 differentiate the load on the surface of the artificial membrane [gf], the length of catheter insertion [cm], and shearing force [gf]. N4 performed effective suctioning of increased amounts of phlegm with smaller loads and shearing
force. The duration for which the catheter tip touches thephlegm may influence the amount of the suctioned phlegm.
S3 in Figure 8 performed suctioning hesitantly. While S6
demonstrated rough suctioning skills, the risk of tracheal
membrane damage was high even though a relatively large
amount of phlegm was suctioned.

Discussion
This study aimed to compare the skill proficiency of the entire tracheal suctioning process between expert and novice
groups via a motion capture system and a catheter control
sensing device developed by us. The two-way ANOVA dem-

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Time [s]100

Hand travel [m]

10

50
30
20
10
Time [s]

100

50

100
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50

Left
Right

With BRs: N1

50

0
0

150

150

40

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Right

20

30
20
10
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0

Right predominance

50

Time [s]

100

50

100
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Right

With BRs: S6

0
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30

10

10

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20

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Right

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30

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40

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Right

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150

Equal pattern

40

With BRs: S9

150

Left
Right

30
20
10
0
0

50

100
Time [s]Left predominance

150

Figure 5. Three patterns of bilateral dorsum manus (BDM) travel distances.
[s]120

102.31

97.97

100
67.05

80
60

69.08
47.06

46.39
32.29

Left BDM Posing Time

33.86

40

21.21

20.01
11.76

20
0

Performance time

Novices

Experts

Right BDM Posing Time

11.1

Novices

Without BRs

Experts

With BRs

Figure 6. Comparison of performance time and posing time of BDM with/without biological reactions (BRs).

onstrated that there is no interrelation between the BRs andthe levels of proficiency. The main effect of performancetime, posing time, and posing frequency was statisticallysignificant; irrespective of the presence of BRs, the experts
performed tracheal suctioning more expeditiously and efficiently. The average performance time of the nursing students was longer without BRs than with BRs. This finding
implies that the presence of BRs may make them to act
hastily. The sensing device could clearly detect hesitance orrough catheter control. There were variations of catheter
control in the load on the surface of the artificial membrane,

the length of catheter insertion, shearing force, and theamount of phlegm suctioned.
The parameters used to assess skill acquisition of tracheal
suctioning was not standardized (Osanai et al., 2019); however, these results indicated that the load on the surface of
the artificial membrane, the length of catheter insertion,
shearing force, and the amount of phlegm suctioned as wellas performance time, posing time, and posing frequency
could be educational criteria for tracheal suctioning with/without BRs.
Majima et al. (2012) conducted research that evaluated
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Posing frequency of Left BDM
30
25
20
15
10
5
0

N01 N02

N03

N04

N05

N06

N08

N09

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Without BRs[Count]

S03

S06

S08

S09

S10

S12

S13

S06

S08

S09

S10

S12

S13

With BRs

Posing frequency of Right BDM
30
25
20
15
10
5
0

N01 N02

N03

N04

N05

N06

N08

N09

S01

S03

Figure 7. Posing frequency of BDM with/without BRs.

nursing students’ skill proficiency for performing intravenous injections by using motion sensors on students’ fingers
and reported enhanced learning effectiveness with prompt
feedback. Depending on which nursing skill was evaluated,
the appropriate location and numbers of motion sensors may
differ. In addition, Otto (2020) pointed out the importanceof the development of evidence on skills competency when
nursing educators introduce virtual reality simulators as thestudents’ cognition was influenced by the representation ofreality. Thus, several parameters were discovered in this research to assess the tracheal suctioning technique. However,additional research on the standardization of quantitative andqualitative proficiency evaluation methods and the constantdevelopment of the virtual/augmented reality simulator to
improve the tracheal suctioning technique needs to be maintained.
Limitations
The artificial trachea used in this research was a single size.
Experts in real settings may perform tracheal suctioning according to a variety of the tree topology, i.e., airway caliber,
branch orientation, and branching angle (Muthu et al.,2019). Despite the patient ages and tracheas’ tree topology,
the identification of hygienic and safe catheter handling isrequired. This research methodology did not involve measuring hand-eye coordination.
8 of 11Conclusions
Herein, we explored the performance time, pelvic forwardbending angle, travel distance of the BDM, posing time andposing frequency of the BDM, and the suctioning catheter
control information between two different proficiency
groups (novice and experts) with/without simulator BRs.
The results of two-way ANOVA showed that these proficiency criteria were not affected irrespective of whether BRs
were used or the levels of proficiency. The main effect ofperformance time, posing time, and posing frequency wasstatistically significant; the experts performed tracheal suctioning more expeditiously and efficiently. The ESTE-SD
clearly detected hesitant or rough catheter controls; There
were catheter control variations. Additional studies on thestatistical analysis of the data obtained from the ESTE-SD
as well as cognitive functioning related to the decisionmaking of the need for tracheal suctioning, the assessmentof the quantity and quality of suctioned phlegm, and the accuracy of hygienic manipulation and safe catheter control,
may be required to develop proficiency evaluation schemes.
Acknowledgments
This work was supported by JSPS KAKENHI under Grant
17H04425, 19H03877.

https://doi.org/10.53044/jinr.2021-0016

Load (gf)50

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N4 (2.22 g)

0
0

5

10

Position (cm)

−50

20

25

Time (sec) 30

20

25Time (sec) 30

20

25Time (sec) 30

20

25Time (sec) 30

20

25Time (sec)30

20

25Time (sec)30

20

25Time (sec) 30

20

25Time (sec) 30

20

25Time (sec) 30

Fx (gf)

20
0

0

5

10

−20

Shearing Force (gf)15

15
X (cm)

50
0
0

5

10

−50

15
Fz (gf)50
S3 (0.13 g)
0

0

5

10

−50

15
Fz (gf)

20
0

5

0

10

−20

15
X (cm)

50
0

5

0

10

−50

Fz (gf)Load (gf)50
0

S6 (1.84 g)

0

5

10

Position (cm)

−50

0

15
Fx (gf)

20
0

5

10

−20

Shearing Force (gf)15

15
X (cm)

50
0

0

−50

5

10

15
Fz (gf)Figure 8. Suctioning catheter movement obtained from ESTE-SD.

9 of 11JINR 2023, 2(1), e2021-0016

Author Contributions
Substantial contributions to the conception of the work; NC,
the data acquisition; NC, SK, KS, KA, SI, interpretation ofdata for the work; NC, SN, SK, drafting the work NC, orrevising it critically for important intellectual content; SK,
AK, SK, SI, MN, SN, final approval of the version to be
published; NC, SK, AK, SK, SI, MN, SN.
Declaration of Conflicting Interests
No potential competing interest was reported by the authors.
Ethical Approval
Approval code: 17-81-2
Name of the institution that granted the approval: Hokkaido University
Data Availability Statement
All data generated or analyzed during this study are included in this published article.
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Original Research

Effects of footbaths on prefrontal cortex activity and autonomic nervous
function: A randomized controlled crossover trial
Kosuke Maeda, PhD , Takako Ohba, MNS , Tomofumi Kato, MNS , and Akihiro Shuda, PhD
Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan

Abstract
Objective: Footbaths are employed in nursing practice in East Asian countries. Assessing the effects of footbaths
based on the findings of multiple physiological responses is relevant to ensuring evidence-based nursing practice.
This study aimed to investigate the effects of thermal stimulation by a footbath on prefrontal cortex activity andautonomic nervous function. Methods: This study was a randomized controlled crossover trial conducted onhealthy participants from a college student population. Each participant underwent a footbath in warm water and acontrol condition for 10 min on two different days. The order of the two treatments was randomized. The oxygenated hemoglobin concentration in the prefrontal cortex, laterality scores of the oxygenated hemoglobin concentration changes, and autonomic responses were evaluated. Results: A total of 17 healthy participants were recruited.
A footbath in warm water significantly reduced both the prefrontal cortex and sympathetic nerve activities 7 min after the start of the footbath compared with the control condition. Moreover, a footbath in warm water tended to activate the left prefrontal cortex rather than the right prefrontal cortex. Conclusions: The changes in the prefrontal
cortex activity and autonomic nervous function were associated with the relaxing effect of the thermal stimulationby the footbath. Furthermore, this effect was highest at 7 min after the start of the footbath. This study has the potential to contribute to the evidence-based use of footbaths. Trial Registration: UMIN-CTR Clinical Trial: UMIN
000033735
Keywords
footbath, prefrontal cortex activity, autonomic nervous function, near-infrared spectroscopy
JINR 2023, 2(1), e2021-0027

Introduction
Footbath is a frequently performed nursing practice in East
Asian countries, particularly in Japan (Choi & Song, 2017).
This nursing practice helps maintain the foot’s skin integrity
or function. In addition, it influences human physiology andmental function. For example, a study assessing the effects
of footbaths on autonomic activity using heart rate variability (HRV) demonstrated that at 40°C, it increases parasympathetic nerve activity associated with physical relaxation(Saeki, 2000). Furthermore, a footbath in warm water sup-presses arteriosclerosis (Kobayashi et al., 2019), promotes
sleep (Kim et al., 2016), and improves muscle tone (Matsumoto et al., 2014). Therefore, it is clear that warm stimulation of the feet has multiple effects on the human body.
It is generally believed that thermal stimulation by a footbath provides subjective pleasantness. Pleasant/unpleasantemotions are associated with prefrontal cortex activity
within the central nervous system (Hoshi et al., 2011). A
functional magnetic resonance imaging (fMRI) study demonstrated that pleasantness from thermal stimulation was associated with the caudate nucleus and frontal regions (Ai-Correspondence: K. Maeda. Email: k-maeda@tmu.ac.jp
Received: November 12, 2021, Accepted: March 19, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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zawa et al., 2019). Although a footbath in warm water may
be related to prefrontal cortex activity, thus far, only a few
studies have investigated the effects of a footbath on theprefrontal cortex (Xu & Uebaba, 2003). Some studies havedemonstrated that assessment of the left-right superiority ofprefrontal cortex activity can be used to objectively evaluate
stress (Tanida et al., 2008) and determine if the participants
feel pleasure or discomfort (Tanida et al., 2017). In addition,
it is reported that the prefrontal cortex is not only involvedin cognitive function and emotion but also plays a significant role in the control of autonomic nervous function instress response (Buijs & van Eden, 2000). Therefore, to scientifically elucidate the effects of footbath in warm water, it
is important to measure not only the effect of the footbathon prefrontal cortex activity but also the differences in theactivity of the left-right hemispheres of the prefrontal cortex
and the effect on the autonomic nervous function. Assessing
the effects of footbath in warm water, based on the findingsof multiple physiological responses, may contribute to theprovision of evidence-based nursing practices.
Previous studies have compared data obtained before andafter a footbath (Saeki, 2000; Saeki et al., 2007; Yamamoto
et al., 2008) and reported on the comparisons between conditions with and without footbaths (Choi & Song, 2017; Kobayashi et al., 2019; Matsumoto et al., 2014). However, in
this study, to confirm the effects of thermal stimulation by afootbath, we performed the footbath under both the intervention and control conditions. This difference could eliminate
the previously overlooked effects of hydrostatic pressure andbuoyancy.
This study aimed to investigate the effect of thermal
stimulation using a footbath by measuring prefrontal cortex
activity and the autonomic nervous function simultaneously.
We examined cerebral activity and autonomic nervous function using near-infrared spectroscopy (NIRS) and spectral
analysis of HRV, respectively. Laterality scores (Tanida etal., 2004) were used to evaluate the left-right superiority ofprefrontal cortex activities. To evaluate the impact of thewarm sensation of a footbath, we performed the footbaths at
two different temperatures.

Materials and Methods
Participants
Healthy college students were recruited to obtain fundamental knowledge of the effects of footbaths. Only right-handed
students were included because brain functions differ depending on the dominant hemisphere. The included participants had no history of circulatory organ disorders or leg
skin abnormalities. To eliminate the effects of the sexual cycle, female participants were included in the lowtemperature group based on the measurement of their basal
body temperatures. We calculated the sample size using a
2 of 11https://doi.org/10.53044/jinr.2021-0027

two-tailed test with moderate effect size (d = 0.6), a significance level of 5% (α = 0.05), and a power of 80% (power =0.8) and found that 19 participants were required. To account for potential attrition, 22 participants were included.
Data were collected between December 2018 and February
2019. The study protocol was explained to the participantsverbally and in writing; written informed consent was obtained from them. This research was conducted in accordance with the Declaration of Helsinki, approved by theauthor’s Institutional Ethics Committee (18029), and enrolled as a clinical trial (UMIN-CTR Clinical Trial: UMIN
000033735).
Footbath Method
A randomized controlled crossover trial was employed for
all the study participants. All experiments were conducted ina quiet laboratory in which the room temperature was controlled within the range of 23°C-25°C. The participants
rested for 300 s prior to starting the footbath (rest period).
For the last 30 s during the rest period, they were instructed
to place their feet on a platform next to the footbath. Subsequently, they undertook one of the following two protocols
in a sitting position: (1) a footbath in which both feet aresoaked in warm water at the lower leg skin surface temperature + 10°C (footbath in warm water [WFB]) or (2) a footbath in which both feet are soaked in warm water at thelower leg skin surface temperature (control condition). Thermal sensation of local heat or cold was initially determinedby the skin temperature without any influence of core bodytemperature or environmental condition (Aizawa et al.,2019). When the footbath temperature is set to a certain
temperature, the perceptions of temperature sensations, suchas hot or lukewarm, differ according to subject-specific characteristics. When nurses perform WFB, they customize the
WFB temperature according to the skin temperature of eachpatient’s lower leg and the patient’s temperature preference
rather than using the fixed temperature described in nursing
textbooks. Therefore, to reduce the variability of the participants’ temperature sensations, in this study, the WFB temperature was set according to the skin temperature of eachpatient’s lower leg. Based on a report (Xu & Uebaba, 2003)
that the appropriate time and temperature for a safe footbath
is 600 s at 42°C or 900 s at 40°C, the WFB condition inthis study was set to be the lower leg skin surface temperature + 10°C to set a safe water temperature not exceeding
42°C.
The footbaths lasted a total of 10 min (Figure 1). The
water was filled to 6 cm higher than the top of each participant’s external malleolus as temperature sensations differ depending on the depth at which the feet are soaked. Although
footbaths often include simultaneous body scrubbing andmassage, such procedures were not performed in this study’s
protocol, which was limited to only soaking both feet.

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JINR 2023, 2(1), e2021-0027

Footbathing (10 min)WFB or Control

Rest period(300 s)Measurements

1

2

3

4

5

6

7

8

9 10 (min)NIRS and ECG
Subjective thermal sensations andsubjective pleasantness levels
MRI imageTaken before the experiment

Figure 1. Experimental design. The subjective index survey is conducted following the footbath at both time points.
Arrows and ↑ indicate measurement times; Control, control condition; ECG, electrocardiography; MRI, magnetic resonance imaging; NIRS, near-infrared spectroscopy; WFB, footbath inwarm water.

The participants were instructed to close their eyes toeliminate visual information that could affect their cerebral
activity and to avoid sleeping during the footbaths. Each ofthem was randomly allocated to the WFB or control conditions on different days.
Measurements
Prefrontal Cortex Activity (NIRS)
Changes in regional cerebral blood flow induced by sensory
stimulation are used as an alternative marker to neural activity changes (Matsuura & Kanno, 2001). When the nerve isactive, more oxygen is sent to the site of nerve activity thanthe brain tissue needs. In other words, when a part of thebrain is active, the blood flow to that part of the brain increases. In this study, the cerebral hemodynamics in the prefrontal cortex were measured using the functional NIRS system (LabNIRS, Shimadzu Corp., Japan). This system canmeasure fluctuations in the concentrations of oxygenated,deoxygenated, and total hemoglobin (oxy-Hb, deoxy-Hb,
and total-Bb, respectively). When interpreting the NIRS signals, oxy-Hb is considered to be the parameter that best reflects brain activity as it is associated with regional cerebral
blood flow (Hoshi et al., 2001). In addition, in a study
where magnetic resonance imaging (MRI) and NIRS measurements were simultaneously performed, the authors reported a correlation between oxy-Hb measured via NIRS
and the BOLD signal of MRI (Okamoto et al., 2004).
Therefore, in this study, we used fluctuations in the oxy-Hb
concentration as an indicator of prefrontal cortex activity.
The oxy-Hb concentration on the forehead was measured
with 42 channels (CH) using a forehead fiber holder (Figure2). The probe for each CH was placed according to the International 10-20 system. The oxy-Hb concentration was
continuously assessed during the rest period and the footbath.

Magnetic Resonance Imaging
MRI scans were used to identify the brain regions for each
CH of NIRS. A clinical MRI device (Achieva 3.0T, Philips
Japan, Ltd., Japan) was used to capture images before theexperiment. The entire brain was captured using a T1weighted three-dimensional gradient echo.
Autonomic Nervous Activity and Heart Rate
The autonomic nervous activity and heart rate were measured via electrocardiography (WEB-1000, Nihon Kohden
Corp., Japan). Similar to the oxy-Hb concentration, they
were continuously examined during the rest period and thefootbath.
Subjective Thermal Sensations and Pleasantness Levels
To validate the sensation induced by the footbath among theparticipants, the subjective thermal sensations and pleasantness levels were investigated using a visual analogue scale(VAS). For the former and the latter, the points at 0 and 100
mm were considered cold and hot and unpleasant and pleasant, respectively. We assessed each participant’s sensations at
two points: immediately after the initiation and at the termination of the footbath.
Analysis Methods
NIRS Data and MRI Images
The NIRS signals were sampled at a rate of 10 Hz. The data
were smoothed and provided every 2 s. The oxy-Hb wasprocessed using a band-pass filter. The high-pass filter was
set to 0.0056 Hz (Ozawa & Hiraki, 2017) and the low-passfilter to 0.5 Hz (Kirilina et al., 2012). NIRS measurement
data have fluctuations of varying degrees in various frequency bands (physiological fluctuations). To reduce the impact of this variation, the primary line connecting the preintervention and post-intervention data needs to be treated as
the baseline for analysis. A linear baseline correction wasmade using the mean value of the first 200 s of the rest period and the 30 s immediately after the end of the footbath.
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illuminatorAdetector
Right

midline

Left

3 cm

3 cm

ch1
ch9

ch2
ch10

ch18

ch11
ch19

ch27

ch26
ch35

ch3
ch12
ch20
ch28

ch36

ch4
ch13
ch21
ch29

ch37

ch5
ch14
ch22
ch30

ch38

ch6

ch7
ch15

ch23
ch31

ch39

ch16
ch24

ch32
ch40

ch8
ch17
ch25
ch33

ch41

ch34
ch42

B

Right

Left

Prefrontal cortex

Figure 2. (A) Positions of the light guides. The oxy-Hb concentration changes are measured in
42 areas (channel, CH) between each pair of illuminators and detectors. (B) Brain area beneaththe light guide in a participant. White dots are the illuminators; black dots, detectors; and graydots, CH. oxy-Hb, oxygenated hemoglobin.

The oxy-Hb concentration data measured via NIRS shows
the amount of change relative to the starting point, and thedata in this state cannot be statistically processed. To conduct statistical analysis, the data of each participant must be
standardized into scores. The z-score is one of the standard
scoring methods. The z-score was calculated using the formula z-score = (mean data − mean baseline)/the standard
deviations (SDs) of baseline, and the average value of therest period from 200 to 260 s was used as the baseline data(baseline). The NIRS data were hence transformed into zscores ranging from 0 to 1 (Matsuda & Hiraki, 2006). For
artifact rejection, all values between the sampling data andtheir SDs were calculated, and data exceeding ±8 SDs were
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excluded from the analysis (Ozawa et al., 2014).
The brain MRI images of each participant were superimposed on the probes and the CHs of the NIRS using MRI
image superposition software (Fusion, Shimadzu Corp., Japan). Because the shape and size of the brain differ among
the participants, two researchers confirmed the positions of
the CHs on MRI images. Based on the Brodmann area, theCHs were located in the frontal pole (Ba10) and the dorsolateral prefrontal cortex (Ba9/46). Although the stimulation
method was different from that used in this study, changes
in cerebral blood flow in the regions of Ba10 (Minematsu etal., 2018) and Ba9/46 (Billot et al., 2017) have been reported to be related to sensations of pleasantness and un-https://doi.org/10.53044/jinr.2021-0027

JINR 2023, 2(1), e2021-0027

Enrollment

Assessed for eligibility(n = 25)
Excluded (n = 3)
− Not meeting inclusion
criteria (n = 2)
− Other reasons (n = 1)
Randomized(n = 22)

Lost after randomization (n = 5)
− Bradycardia (n = 2)
− Noise were mixed in the data(n = 3)Control(n = 17)

interval
1 day or
more

WFB
(n = 17)

Figure 3. Participant flow chart.
Control, control condition; WFB, footbath in warm water.

pleasantness. To examine the effects of footbaths using multiple physiological responses, this study focused on the superstructure (prefrontal cortex) of Ba10 and Ba9/46 rather
than analyzing each region in detail. The activity of the left
prefrontal cortex was measured by the CH of Ba10 andBa9/46 in the left prefrontal cortex, whereas the activity of
the right prefrontal cortex was measured by the CH of Ba10
and Ba9/46 in the right prefrontal cortex.
To confirm the gradual change during the footbath, wegrouped the data in 60-s intervals and analyzed all the data
at every 60 s. The z-score for every 2 s was used to calculate the average alteration in the value for each period relative to the baseline. Because the data obtained were nonnormally distributed, differences in cerebral blood flow inboth the left and right prefrontal cortices between the WFB
and control conditions were statistically analyzed using the
Wilcoxon signed-rank test.
To evaluate the asymmetry of the oxy-Hb concentration
changes in the right and left prefrontal cortices, we calculated the laterality ratio scores for each period. (i.e., [(right− left)/(right + left), changes in z-score]) (Tanida et al.,2004). Positive laterality ratio scores indicated that the increase in the oxy-Hb concentration in the right prefrontal
cortex was larger than that in the left, whereas negativescores indicate a reverse relationship.
Autonomic Nervous Activity and Heart Rate
The HRV was calculated from the R-R intervals of the electrocardiogram using the maximum entropy method for spectral analysis (MemCalc/Tarawa, GMS Corp., Japan). The ar-eas of the two components of the spectral analysis were
measured by integrating the low-frequency (LF; 0.02-0.15
Hz) and high-frequency (HF; 0.15-0.40 Hz) components;
moreover, the LF/HF ratio was calculated. Autonomic nervous system activity was assessed assuming that HF and LF/
HF represented parasympathetic and sympathetic nervous
system activities, respectively.
The sample period used for analysis lasted a total of 60 s.
HF and LF/HF were used to calculate the change in value
for each period relative to the baseline. Since the data were
non-normally distributed, the Wilcoxon signed-rank tests
were employed to analyze HF and LF/HF. The heart rate
data were normally distributed and, therefore, analyzed using a paired t-test.
Subjective Thermal Sensations and Pleasantness Levels
Because the subjective thermal sensation and pleasantnesslevel data were non-normally distributed, the Wilcoxon
signed-rank test was conducted to identify the differences
between the WFB and control conditions at each time point(at the start and end of the footbath).

Results
A flowchart of the experiments is represented in Figure 3.
The characteristics at baseline of the 17 healthy participants
included in the analysis are presented in Table 1. The mean
WFB temperature was 38.5°C ± 1.6°C, and that of the control condition was 27.5°C ± 1.4°C. The temperature and humidity of the experimental room were 23.6°C ± 0.4°C and
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Table 1. Selected participant characteristics.
Age, years (SD)Sex, n (%)
Men
Women
Anthropometric measures
Height, cm (SD)
Body weight, kg (SD)
BMI, kg/m2 (SD)
Hemodynamic measures
Heart rate, bpm (SD)
Systolic BP, mmHg (SD)Diastolic BP, mmHg (SD)
Temperature of the skin surface of thelower limbs, °C (SD)28.4% ± 5.1%, respectively. All data were analyzed for differences in the order of the experiments and sex; however,no significant effects of these differences were noted.
No differences were observed in heart rates between the
WFB and control conditions (Figure 4). The WFB condition
was warmer and more pleasant than the control condition,
showing significantly higher subjective thermal sensations
and subjective pleasantness levels than the control conditionat all time points (Table 2).

20.9 (1.2)
7 (41)
10 (59)163.3 (9.7)
56.4 (7.8)
21.1 (2.1)

NIRS Data (Prefrontal Cortex Activity)

71.9 (7.0)
108.1 (9.7)
68.4 (8.0)
27.7 (2.5)

Figure 5 presents the cerebral blood flow in the prefrontal
cortex. No significant differences were observed at baseline
between the WFB and control conditions. At the 1-min time
period, the WFB’s z-score was significantly higher than thatof the control condition (r = −1.96, p < .001); however, atthe 7-min time point, it demonstrated a significantly lower

Notes. BMI, body mass index; BP, blood pressure; SD,
standard deviation.

80

bpm

75

70

65

60
baseline

1

2

3

4

5
WFB

6

7

8

9

Control

10(min)Figure 4. Changes in heart rate.
Paired t-tests are conducted for comparison between the groups.
bpm, beats per minute; Control, control condition; WFB, footbath in warm water.
No statistically significant differences are observed between the groups.

Table 2. Between-group comparisons of the subjective thermal sensations and pleasant levels.
n = 17
Variable and timing
Subjective thermal sensations
Immediately after the start of the footbath
At the end of the footbath
Subjective pleasantness levels
Immediately after the start of the footbath
At the end of the footbath

WFB Median (range)

Control Median (range)

Z valuep value

77 (57–89)
55 (28–72)

24 (1–64)
44 (9–53)−3.622−3.518<.001*<.001*

90 (68–100)
85 (25–100)

52 (16–100)
46 (8–72)−3.527−3.622<.001*<.001*

Notes. The Wilcoxon signed-rank test was conducted for comparison between groups.
Control, control condition; WFB, footbath in warm water.
* A significance level of .05 was observed for the median difference.

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1.0

Z-score

0.5

*

0.0

*
−0.5

−1.0

baseline

1

2

3

4

5
WFB

6

7

8

9

Control

10(min)Figure 5. Changes in cerebral blood flow in the prefrontal cortex.
The Wilcoxon signed-rank test is conducted for comparison between the groups.
Control, control condition; WFB, footbath in warm water.
* A significance level of .05, vs. control condition, is observed for the median difference.
Table 3. The laterality scores of the oxy-Hb
concentration changes.
n = 17
Time period

WFB

Control

1 min
2 min
3 min
4 min
5 min
6 min
7 min
8 min
9 min
10 min

−0.15
−0.09
−0.24
−0.80
−0.70
−0.93
−0.06
−0.52
−0.39
−0.88

0.37
−0.01
−0.14
0.49
0.31
−0.20
−0.38
−0.90
0.19
0.89

Notes. A statistical significance test was not conducted between the conditions.
Control, control condition; oxy-Hb, oxygenatedhemoglobin; WFB, footbath in warm water.

value than the control condition (r = −0.75, p = .002).
The laterality scores of the oxy-Hb concentration changes
are presented in Table 3. When either or both data from thetwo hemispheres showed negative values, the following formula was used to look at the relationship between the left
and right hemispheres in z-score: laterality ratio score =(right − left)/(|right| + |left|). The laterality score of the WFB
was negative at all time points, whereas those of the control
condition were a mixture of positive and negative values.

Autonomic Nervous Activity
Figure 6 present the results of HF and LF/HF, respectively.
No significant differences were observed in both values atbaseline between the WFB and control conditions. Furthermore, there were no significant differences in HF. At the 7min time point, the WFB’s LF/HF was significantly lower
than that in the control condition (r = −0.49, p = .04).

Discussion
Our study was able to accurately investigate the effects of
WFBs on prefrontal cortex activity. The strength of thisstudy is that it capitalized on the use of NIRS probes basedon individual differences in brain shapes captured with MRI.
The NIRS has low spatial resolution for accurately identifying the exact measurement sites (Okamoto & Dan, 2007).
Using both the NIRS and MRI, we were able to identify thelocation of the prefrontal cortex, which was ambiguous in
the previous studies (Xu & Uebaba, 2003). In addition, in
this study, we did not set one temperature of WFB but
changed the temperature of WFB according to the skin temperature of each participant’s lower leg.
In a previous study that used a fixed 40°C footbath temperature, the VAS score for the post-WFB temperature sensation had an interquartile range of 20 (Maeda & Shuda,2018). The VAS score of the post-WFB temperature sensation had an interquartile range of 12 in the present study, using the same measurement method as that described by
Maeda and Shuda (2018); thus, the method in the present
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HF

LF/HF

150

1.0
0.8
LF/HF ratio

msec2

100
50
0

−50
−100
baseline 1

0.6
0.4
*

0.2
0.0

−0.2
2

3

4

5
WFB

6

7
8
Control

9

10
(min)

−0.4
baseline 1

2

3

4

5
WFB

6

7
8
Control

9

10
(min)

Figure 6. Changes in HF and LF/HF.
The Wilcoxon signed-rank test is conducted for comparison between the groups.
Control, control condition; HF, high-frequency components; LF, low-frequency components; WFB, footbath in warm water.
* A significance level of .05, vs. control condition, is observed for the median difference.

study had less variation than the fixed-temperature method.
This suggests that setting the WFB temperature according to
the skin temperature of each participant’s lower leg is able
to better control for individual differences in temperaturesensation than using a fixed temperature. In addition, because of the small individual differences, we were able toevaluate the footbaths practiced by nurses, i.e., customizing
the temperature according to each patient’s lower leg. Therefore, the method used in this study might be able to lead toa new research method that will strengthen the evidence on
nursing practice.
As a result of measuring the gradual changes in prefrontal
cortex activity and autonomic nervous function during thefootbaths, our findings provide evidence that WFBs have arelaxing effect. This conclusion is suggested by the following three considerations:First, the WFB reduced the prefrontal cortex activity 7
min after initiation. Previous report (Xu & Uebaba, 2003)
examining the relationship between WFB and prefrontal cortex blood flow has not investigated the gradual changes during WFB; to the best of our knowledge, this is the firststudy to examine prefrontal cortex blood flow during WFB.
It is known that increases or decreases in the quantity ofblood flow in the brain correspond with those of oxy-Hb,
and it is thought that a decrease in oxy-Hb concentration
causes physiological calming (Hoshi et al., 2001). As a result of evaluating the association between thermal stimulation and brain activity using fMRI, Aizawa et al. (2019) reported that the thermal sensation and whether thermal perception is pleasant or unpleasant may be processed in theinsula and medial prefrontal cortex, respectively. Therefore,
the response of the prefrontal cortex in this study may be
influenced by the pleasantness or unpleasantness induced by
WFB. Fujiwara et al. (2020) investigated the effects of thermal stimulation of the lower limbs via NIRS and electroen8 of 11

cephalography and reported a decrease in cerebral bloodflow in the prefrontal cortex and an increase in α-wave activity. Although the intervention method was different fromthe present study and was emotionally charged audiovisual
stimulation, Matsukawa et al. (2018) employed NIRS andreported that pleasantly charged (comedy) stimulation
caused a substantial decrease in oxy-Hb in all regions of theprefrontal cortex. Although various stimulation methods
have been tested in previous studies, a common finding isthat the relaxation effect significantly reduced the activity ofthe prefrontal cortex. Since the activity of the prefrontal cortex was also significantly decreased in the present study, we
concluded that WFB has a relaxation effect.
Second, the WFB has more of an effect on activation in
the left prefrontal cortex than in the right. The laterality ratio score is negative when the increase in the oxy-Hb concentration in the right prefrontal cortex is less than that in
the left (Tanida et al., 2004). To date, no studies on the footbath have investigated the differences in left-right prefrontal
cortex activities. Although the intervention conditions differed from the present study, Song et al. (2017) found thatviewing fresh roses significantly decreased the oxy-Hb concentration in the right prefrontal cortex and increased theperception of feeling “comfortable,” “relaxed,” and “natural,”indicating that viewing fresh roses induces physiological andpsychological relaxation. Silveira et al. (2019) reviewed apositive psychological response to exercise and suggested
that a higher left prefrontal cortex activation was associatedwith a positive psychological response to exercise. Tanida etal. (2008) reported that the relaxing effect of fragrances was
associated with a change in the dominant activity in the prefrontal cortex from the right to the left side. Our study
showed a dominant response in the left prefrontal cortex,
which indicates a pleasure-related response suggesting that
WFBs have a relaxing effect.

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Third, the WFB reduced sympathetic activity without incurring fluctuations in parasympathetic nerve activity. A report of a 10-min footbath suggested that this effect was associated with an increase in HF and a decrease in LF/HF(Saeki et al., 2007). Although the method of footbath andthe duration of footbath differed, Yamamoto et al. (2008)
compared the use and non-use of a 20-min footbath at 42°C
and reported that HF did not show a significant change during the footbath, but the LF/HF ratio significantly reduced.
Our LF/HF results agree with the findings of these studies.
However, our study examined the gradual changes in WFB
and found that a decrease in LF/HF occurred 7 min after thestart of WFB. Thus, sympathetic nerve activity significantly
decreases 7 min after starting a footbath, and the autonomic
nervous system changes to a more relaxed state.
The findings of this study demonstrate that WFBs inducea relaxing effect. Based on the reaction time of prefrontal
cortex and sympathetic nerve activities, it can be inferredthat the relaxing effect would be highest at 7 min after thestart of the footbath. According to descriptive statistics, at 410 min during the footbath, HF was higher and LF/HF was
lower compared with the control condition, and the laterality
ratio score had negative values, suggesting that WFBs mightalso have a relaxing effect at 4-10 min. However, themechanism of these responses could not be identified. This
study was the first to investigate gradual changes caused by
footbaths; if the physiological mechanisms of WFBs were
known in more detail, we would be a step closer to identifying the pathway for the relaxing effects of WFBs. Stress is asignificant risk factor for various diseases, such as hypertension, heart attack, stroke, and even sudden death (Attar etal., 2021). Although further study is needed to determine theextent to which the relaxing effect of WFBs leads to stressrelief, this study provides evidence that WFBs in nursing
practices may be beneficial to healthcare.
A significant increase in prefrontal cortex activity immediately after starting the footbath was confirmed only in participants under the WFB condition. Uebaba and Xu (2004)
reported that a 38℃ footbath did not change the concentration of oxy-Hb in the prefrontal cortex compared with theresting state. In addition to the thermal effect, footbaths contain many stimuli, such as hydrostatic pressure and buoyancy. In our study, we eliminated the effects of hydrostaticpressure and buoyancy by performing the footbath in boththe intervention and control conditions. However, it was notclear from this study if the difference from the results ofUebaba and Xu (2004) was due to the hydrostatic pressure
and buoyancy. As footbaths include many stimuli, more detailed studies are needed in the future to understand the effects of hydrostatic pressure and buoyancy to strengthen theevidence on the effects of footbaths.
In this study, we focused on the superstructure, prefrontal
cortex, and effects of WFB on Ba10 and Ba9/46, and other

JINR 2023, 2(1), e2021-0027

brain regions were not individually examined. Additionally,
only the oxy-Hb concentrations were analyzed, and data forthe deoxy-Hb concentrations and total-Hb concentrations
were not considered. To strengthen the evidence for WFB, it
is important to elucidate the detailed neural responses andneural mechanisms affected by WFB. Although the magnitude of the effect of WFB on prefrontal activity could not
be examined due to the characteristics of the NIRS data, thegradual changes in cerebral blood flow and the left-right superiority of prefrontal activity were confirmed, which willcontribute to the development of WFB research in the future.
We were able to assess the response of both prefrontal
cortex and autonomic nervous activities to WFB. However,
the evaluation of the direct connection between prefrontal
cortex activity and autonomic nerve responses remains unsatisfactory. It was not feasible to determine whether cerebral activity affected autonomic nervous activity and viceversa. Furthermore, data were obtained under restricted experimental conditions, and the duration of these effects andtheir associated changes due to repeated implementation
could not be assessed. Further research is needed to determine details such as the appearance time of the footbath effect and the increase or decrease in the effect due to repeated execution.
The present study identified that a WFB evokes significant decreases in prefrontal cortex and sympathetic nerve
activities after 7 min. In addition, left-dominant prefrontal
responses were observed at all time periods. These findings
indicate that WFBs have a relaxing effect, and this effect ishighest at 7 min after the start of the footbath. This researchcontributes to evidence-based nursing practices involving
warm footbaths. Furthermore, given the likelihood that theseeffects are beneficial to health, our outcomes support the useof warm footbaths in nursing practices.
Acknowledgments
We would like to express our gratitude to Tomokazu Numano for their assistance with the data collection. We would
also like to thank Editage (www.editage.com) for English
language editing.
Author Contributions
Kosuke Maeda: Conceptualization, methodology, validation,formal analysis, investigation, writing-original draft, writingreview & editing, project administration, funding acquisition. Takako Ohba: Formal analysis, investigation, writingreview & editing. Tomofumi Kato: Formal analysis, investigation, writing-review & editing. Akihiro Shuda: Formal
analysis, writing-review & editing, supervision.
Declaration of Conflicting Interests
The authors declare that there are no conflicts of interest.
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Ethical Approval
The study protocol was explained to the participants verbally and in writing, and written informed consent was obtained from each participant. This research was conducted inaccordance with the Declaration of Helsinki, approved by
the author’s Institutional Ethics Committee (18029), and enrolled in the clinical trial (UMIN-CTR Clinical Trial: UMIN
000033735).
Funding
This study was supported by the Ministry of Education,
Culture, Sports, Science, and Technology (MEXT) KAKENHI Grant Number 16K20719.
Data Sharing
Available types of data: Data available upon request fromthe authors.
Available documents: Study Protocol
Available dates: Beginning 9 mon and ending 36 mon following article publication.
With whom the data are available: Investigators whose
proposed use of the data has been approved by an independent review committee identified for this purpose.
Types of analyses the authors are willing to share thedata: For individual participant data meta-analysis.
Method of requesting the data: Proposals may be submitted up to 36 mon following article publication. After 36
mon, the data will be available in our University’s data
warehouse but without investigator support other than deposited metadata. Information regarding submitting proposals and accessing data may be found at https://upload.umin.
ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000038467.
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11 of 11

https://doi.org/10.53044/jinr.2021-0011
https://www.jinr.jsnr.or.jp/

Original Research

Collaborative visits by hospital specialist nurses with homecare nurses:
A nationwide, cross-sectional, web-based survey
Aruha Masuda, MHS, RN, PHN1 , Mariko Sakka, PhD, RN1 , Satomi Kitamura, PhD, RN1 ,Ayumi Igarashi, PhD, RN1 , Maiko Noguchi-Watanabe, PhD, RN1 , Akiko Araki, DNSc, RN2 , andNoriko Yamamoto-Mitani, PhD, RN1
1

Department of Gerontological Home Care and Long-term Care Nursing, Division of Health Science and Nursing,
Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, and 2Japanese Nursing Association, Tokyo,
Japan

Abstract
Objective: Hospital-based specialist nurses (clinical nurse specialists and certified nurses) are increasingly conducting patient home visits along with homecare nurses due to the increasing necessity of home care for persons
with multiple medical needs. However, not much is known about such visits. Thus, this study examines collaborative visits by specialist nurses. Methods: A web-based questionnaire survey was sent to specialist nurses in Japan specializing in (1) wound care, (2) cancer palliative care, and (3) chronic disease care. Multiple logistic regression analyses were performed to identify the factors involved in collaborative visits, focusing not only on theindividual but also on hospital/community characteristics. Results: Data from 1,027 specialist nurses were analyzed. Among them, 45.6%, 21.4%, and 18.3% of wound care, cancer palliative care, and chronic disease nurses,
respectively, conducted collaborative visits. For nurses specializing in wound and cancer palliative care, holding
managerial positions was associated with providing collaborative visits. Wound care nurses from hospitals in municipalities with fewer hospital beds per capita tended to conduct collaborative visits, whereas cancer palliative
nurses in communities with a higher aging rate provided more collaborative visits. For chronic disease nurses,
more working hours as specialists, lower participation rates in community-based multidisciplinary gatherings, andworking in hospitals with open community consultation services promoted collaborative visits. Conclusions: Hospital and community factors are associated with collaborative visits, suggesting a need for hospital-wide andpolicy-supported efforts to further increase collaborative visits.
Keywords
advanced practice nursing, chronic disease, community-institutional relations, community integrated care system,
homecare
JINR 2023, 2(1), e2021-0011

Introduction
Considering rapid societal changes, e.g., population aging,nurses in several countries have been exploring new systems
of providing nursing services, for example, advanced prac-

tice nursing, where registered nurses are provided additional
education. Reflecting on the international awareness of andinterest in promoting advanced practice nursing, the International Council of Nurses has established a committee on advanced practice nursing (International Council of Nurses, n.

Correspondence: A. Masuda. Email: aruha-masuda@g.ecc.u-tokyo.ac.jp
Received: July 19, 2021, Accepted: May 19, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 9JINR 2023, 2(1), e2021-0011d.). Nurses in Japan have also started exploring service provision in the face of rapid population aging.
Several types of additional specialist certification education for registered nurses exist in Japan. Both certified
nurses (CNs) and certified nurse specialists (CNSs) are specialist nurses who have received advanced education in a
specialty and have been certified by the Japanese Nursing
Association. They have at least 5 years of clinical experience as a registered nurse in a particular field and havecompleted a 2-year master’s program (CNSs) or a 6-monthcertification program (CNs). Their core competencies include (1) high-level nursing practices, (2) the ability to instruct staff nurses, and (3) the ability to provide consultation. CNSs are also expected to take on research and ethicalcoordination roles (Japanese Nursing Association, 2016).
Moreover, about 20,000 CNs and 2,000 CNSs are currently
available (Japanese Nursing Association, 2019). CNs may
specialize in 21 different fields (e.g., wound, ostomy, andcontinence care [WOC] nursing, palliative care, and infection control), while CNSs specialize in 13 fields (e.g., oncology, psychiatric/mental health, and critical care). Approximately 90% of CNs and CNSs are working in hospitalsettings.
Developing new specialist nurses and determining how
they should work in the healthcare system are being explored in numerous countries (Donald et al., 2013; Yao etal., 2017; O’Flynn, 2018). Japan is characterized by its extreme increase in the aged population. To meet the healthcare needs of numerous older adults, Japan has recently focused on providing home-based care outside hospital settings (Ministry of Health, Labour and Welfare, 2016a). Further, community dwellers also require advanced medicalcare. Thus, specialist nurses (SNs), representatively CNs and
CNSs, with specific knowledge and skills, are encouraged toprovide advanced care in homecare settings (Japanese Nursing Association, 2019). The same trend of SNs working outside the hospital setting is observed in other countries (Adams, 2015; Clevenger et al., 2020). Earlier studies report thebenefits of SNs on client outcomes, e.g., decreasing readmission rates and improving quality of life through homecare (e.g., Adams, 2015).
Collaborative visits entail SNs working outside the hospital with homecare nurses. They have been used since 2012
and are reimbursed under the medical insurance system.
When a homecare nurse faces difficulties due to client problems, they can request a nearby hospital that employs SNs
to conduct a collaborative visit. For example, a WOC SN
visits the client with the homecare nurse and provides directcare or consultation when homecare nurses have difficulty intreating their client’s pressure ulcer. A regular homecare
nursing visit currently costs about $72/h. For each collaborative visit, an approximately additional $120 is reimbursed tothe hospital to which the SN belongs. This reimbursement is
2 of 9https://doi.org/10.53044/jinr.2021-0011

for two specialty areas only: pressure ulcers and colostomy
care and palliative care (Ministry of Health, Labour andWelfare, 2012). Care of chronic diseases is not covered.
In countries, e.g., Japan, experiencing rapid population
aging, collaborative visits play an important role in optimizing home healthcare. However, few studies have reported on
the current status of collaborative visits. The only related
survey was conducted in 2016 involving WOC CNs, amongwhom less than a third had conducted collaborative visits(Kaitani et al., 2017). While the importance of collaboration
between SNs and homecare nurses in the community is generally recognized, the prevalence of collaborative visits ineach specialty and the factors that encourage those visits remain unclear. To promote collaborative visits in Japan andshare experiences of that in other countries, further examination of their characteristics and associated factors would be
beneficial. Hence, this study describes collaborative home
visits made by hospital SNs from the perspective of thoseSNs and by linking their descriptions to hospital and community statistics. Both hospital and community characteristics were considered in this study to determine the factorsthat promote collaborative visits among different hospitals
and communities. Examining these factors will help promote
the effective functioning of advanced practice nurses not
only within the hospital setting but also in the community.

Materials and Methods
Study Design
This study used a web-based, cross-sectional questionnaire
survey design.
Participants
The participants of the study were CNs and CNSs employed. All CNs and CNSs all over Japan were invited. As
reimbursements for collaborative visits are currently only
available for two specialties―pressure ulcers and colostomy
care and cancer palliative care (Ministry of Health, Labourand Welfare, 2012) ―this study included CNs and CNSs
from the following five related fields: WOC, palliative care,cancer pain management, breast cancer CNs, and oncology
CNSs. This study also included SNs from the following fivespecialties for frequent chronic diseases for which reimbursements are not yet available: CNs in diabetes, dialysis,
respiratory, and heart diseases, and CNSs for chronic conditions. Nurses who were on leave were excluded from thestudy.
Data Collection
A web-based questionnaire survey distributed through a linke-mailed to all listed CNs and CNSs (n = 23,201) was used.
The participants answered questions anonymously after reading the explanatory document on the survey website andhttps://doi.org/10.53044/jinr.2021-0011

providing informed consent. Once the dataset was constructed, existing community statistics were added to examine possible associations between the provision of collaborative visits and community characteristics. The survey was
conducted from August to September 2019.
Measures
The authors used an investigator-developed survey and nationally available statistics. Data on SNs’ individual, hospital, and community characteristics as well as whether they
had provided collaborative visits in the community were collected.
SN’s Collaborative Visits
To examine the prevalence of collaborative visits, the participants were asked: “Have you ever conducted collaborative visits with a homecare nurse?” Response options were
“yes” or “no.”SN’s Individual Characteristics
Individual demographic variables included specialty, sex,age, completion of additional training for specific medical
procedures (tokutei koi kensyu), participants’ work positionsin the hospital, and the hospital department they belonged.
Training for specific medical procedures (tokutei koi kensyu)
is a recently introduced program that enables nurses to conduct a specific treatment without receiving a specific individual order from a physician (Ministry of Health, Labourand Welfare, 2015).
Based on earlier studies (Kaitani et al., 2017; Riordan etal., 2017), a question about work characteristics was also included: full-time work as an SN or not, voluntary participation in community-based multidisciplinary gatherings, voluntary participation in seminars in the community, the presence of independent SN-led clinics within the hospital, andtheir working hours as SNs.
Hospital Characteristics
The hospital characteristics considered in this study included
the number of beds, presence of a consultation counter forcommunity people/professionals, presence of a homecare
nurse department in the hospital, presence of a long-term
nursing facility on the premises, and advertisement of SNs’practice in the community by posting on websites and creating leaflets.
Community Characteristics
Following a prior study that indicated that the number ofhospital beds in the community was related to the utilizationof homecare nursing services (Nakanishi et al., 2017), community characteristics were also included in the study. The
participants were first asked to name the municipality inwhich their hospital is located. Next, specific data on municipality type, aging rate, and the number of hospital beds/
population were separately collected. National data on the
aging rate and the number of hospital beds/population fromthe national census and the survey of medical institutions

JINR 2023, 2(1), e2021-0011

were then obtained (Statistical Bureau of Japan, Ministry ofInternal Affairs and Communications, 2015; Ministry of
Health, Labour and Welfare, 2016b).
For municipality type, cities were divided into ordinancedesignated cities and others. The former is a large city witha population of 500,000 or more. In this study, the 23 special wards in Tokyo were considered ordinance-designatedcities. Tasks concerning social welfare, health and hygiene,
and city planning and construction are reassigned from theprefecture to the ordinance-designated cities and the 23 special wards of Tokyo.
Data Analyses
This study classified the 10 SN fields (eight under CN and
two under CNS) into three groups: (1) WOC (WOC CNs);(2) cancer palliative care (palliative care, cancer pain management, breast cancer CNs, and oncology CNSs); and (3)care for chronic diseases (diabetes, dialysis, chronic respiratory care, chronic heart failure CNs, and chronic care
CNSs). This was done to examine field-related differences
and the impact of medical reimbursement availability because medical reimbursement is only available for the firsttwo groups (Ministry of Health, Labour and Welfare, 2012).
Bivariate analyses were first conducted to examine the associations between individual, hospital, and community
characteristics with the provision of collaborative visits. For
categorical variables, the chi-square test was used. Fisher’s
exact test was used when the contingency tables had 20% ormore of the cells with five or fewer observations. For continuous variables, t and U tests were applied to variables
with normal and non-normal distributions, respectively. Subsequently, multiple logistic regression analyses were performed to identify the factors associated with the provisionof collaborative visits (dependent variable) by group. Basedon earlier studies, the following were considered independent variables: age, working status, work location, working
hours as an SN, participation in community-based multidisciplinary gatherings, having a community consultation
counter, advertising SNs’ practice in the community (Doodyet al., 2017; Harvey et al., 2017; Kaitani et al., 2017;
McAiney et al., 2017; Riordan et al., 2017; Sevilla et al.,2018), and other variables with p < .05 as a result of bivariate analyses in each group.
The analyses used IBM SPSS 26.0 for Windows, and thesignificance level was p < .05 (two-tailed). No data were
missing in this analysis because the web-based questionnaire
prevents respondents from leaving any questions unanswered.
Ethical Considerations
A research ethics committee of the university to which theauthor is affiliated approved the study. The questionnaire included an explanation of the study’s purpose and method
3 of 9JINR 2023, 2(1), e2021-0011

https://doi.org/10.53044/jinr.2021-0011

All CNs and CNSs n = 23,201(WOC
n = 2,542)(Cancer palliative caren = 4,420)(Care of chronic diseasen = 2,124)

All respondents
n = 2,993 (12.9%1))
Resigned or taking leaven = 41
Working at hospitaln = 2,952

Ineligible fields
n = 1,675
Not belongs to hospitaln = 54

Eligible participantsn = 1,123Case with any missing datan = 96
Analyzed n = 1,027- WOC
n = 384 (15.1%2))- Cancer palliative caren = 397 (9.0%2))- Care of chronic diseasen = 246 (11.6%2))

Figure 1. Flowchart of participants in this study
Abbreviations: CNs=Certified nurses, CNSs=Certified nurse specialists,
WOC=Wound, ostomy, and continence care. 1) The response rate. 2) The ratio ofvalid responses.

and the voluntary and anonymous nature of participation,with informed consent obtained before participation.

Results
Of the 23,201 SNs to whom the survey was sent, 2,993(12.9%) responded. The response rates among CNs and
CNSs were 12.4% and 18%, respectively. Based on the inclusion and exclusion criteria, 1,027 cases were analyzed according to the three groups, with 384, 397, and 246 specializing in WOC, cancer palliative care, and care for chronic
diseases, respectively, and valid response rates for eachgroup were 15.1%, 9%, and 11.6%, respectively (Figure 1).
More than 90% of the participants were women. Participants’ mean ages were 45.7 ± 6.8, 45.8 ± 6.4, and 44.4 ±6.2 for WOC nurses, cancer palliative care nurses, and carefor chronic disease nurses, respectively. Among the participants, 17.1% worked full-time as SNs, with the fewest SNs
working in care for chronic diseases. Furthermore, 45.6%,
21.4%, and 18.3% of SNs in WOC, cancer palliative care,and care for chronic diseases conducted collaborative visits,
respectively. In the bivariate analysis, the factors related to
conducting collaborative visits for the WOC group included
higher age, completion of training for specific medical procedures (tokutei koi kensyu), status as managerial nurses,
4 of 9more working hours as SNs, participation in communitybased multidisciplinary gatherings, and higher number ofhospital beds in the community. In the cancer palliative caregroup, related factors included completion of training forspecific medical procedures (tokutei koi kensyu), status asmanagerial nurses, and participation in community-based
multidisciplinary gatherings. In the care for chronic diseasegroup, related factors included more working hours as SNs,
higher number of hospital beds in the community, and having a consultation counter for the community (Table 1).
Multiple logistic regression analyses for the WOC group
showed that the characteristics of nurses significantly associated with conducting collaborative visits included SN’s
higher age (adjusted odds ratio [AOR], 1.04; 95% confidence interval [CI], 1.01-1.08), completion of training forspecific medical procedures (tokutei koi kensyu; AOR, 2.76;
95% CI, 1.49-5.09), having a managerial, rather than staff,
position (AOR, 1.81; 95% CI, 1.07-3.07), working in a hospital with a home care nurse department (AOR, 2.58; 95%
CI, 1.50-4.47), and fewer hospital beds per 1,000 population(AOR, .92; 95% CI, .86-.98). Among cancer palliative careSNs, having a managerial position (AOR, 2.62; 95% CI,
1.40-4.89), working in a hospital with a home care nurse
department (AOR, 1.90; 95% CI, 1.03-3.54), and the municipality with higher aging rates (AOR, 1.10; 95% CI,

72 (32.4)

No(n = 312)

41 (19.6).396

b.040 *331 (83.4)

85 (21.4)

57 (18.3)

9.1 ± 4.1

8.4 ± 3.5

9.7 ± 4.5.002 **e

9.8 ± 5.2

9.4 ± 3.99.9 ± 5.5

19 (7.7)42 (17.1)

109 (44.3)

.097b

.282b

.014b*.896b.017b*

p value

79 (32.1)

209 (85.0)

59 (24.0)

94 (38.2)

87 (43.3) .076b

35 (17.4) .765b

92 (45.8) .329b87 (43.3) .076b

14 (7.0) .253d

44 (21.9) .104b

69 (34.3) .008b**95 (47.3) .019b*

90 (44.8) .034b*75 (37.3) .024b*

10 (22.2)

69 (34.3) .116c

41 (91.1) 168 (83.6) .202b

15 (33.3)

25 (55.6)

30 (66.7)

28 (62.2)

25 (55.6)

27 (60.0) 104 (51.7) .316b

40 (88.9) 173 (86.1) .616b

13 (28.9)

7 (15.6)

17 (37.8)

13 (28.9)

5 (11.1).357e

9.8 ± 5.3

9.6 ± 5.0

9.9 ± 5.4 .703e.002c** 27.1 ± 3.8 27.9 ± 3.3 26.9 ± 3.9 .079c.005c**.304b.003 **b125 (50.8)

118 (48.0)

100 (40.7)

131 (53.3)

213 (86.6).003 ** 100 (40.7)

b

.072

b

.150

b

No
(n = 201)n (%) or mean ± SD

Yes(n = 45,
18.3%)

222 (90.2) 40 (88.9) 182 (90.5) .457d
44.4 ± 6.2 44.0 ± 6.5 44.5 ± 6.2 .598c

All

Having conducted collaborative visits

Care of chronic disease (n = 246)

.001b** 100 (40.7)

97 (31.1) <.001b**74 (87.1) 257 (82.4)

28 (32.9)

44 (51.8)

Ordinance- 115 (29.9) 36 (20.6) 79 (37.8) <.001c** 119 (30.0) 15 (17.6) 104 (33.3)
designated citya% 27.0 ± 4.2 27.6 ± 4.0 26.5 ± 4.3.011c* 26.6 ± 4.1 27.9 ± 4.1 26.2 ± 4.0

50 (28.6)

Yes 334 (87.0) 155 (88.6) 179 (85.6)

91 (23.7)b65 (31.1) <.001b** 141 (35.5)

41 (48.2) 171 (54.8)

212 (53.4)
216 (54.4).034b*.439b

Yes 220 (57.3) 104 (59.4) 116 (55.5)
94 (53.7)

56 (65.9) 159 (51.0)

Yes 159 (41.4)

38 (44.7) 137 (43.9)

175 (44.1).062b.001b** 215 (54.2)

Yes 290 (75.5) 140 (80.0) 150 (71.8)
One day or more 293 (76.3) 147 (84.0) 146 (69.9)(per week)
Large (400–) 174 (45.3) 69 (39.4) 105 (50.2)

53 (62.4) 163 (52.2)

79 (92.9) 257 (82.4)

37 (43.5) 103 (33.0)

26 (30.6) 122 (39.1)

19 (22.4) 133 (42.6).002b** 336 (84.6).025 *

140 (35.3)

.323
.935c

d

p value

1 (.3) <.001d**

Yes 297 (77.3) 148 (84.6) 149 (71.3)

50 (23.9)b.011 *b.001 ** 148 (37.3)b

7 (8.2)45 (52.9) 125 (40.1)

60 (34.3)

8 (2.0)170 (42.8)

Yes 110 (28.6)

Advertising Specialist nurses’
practice to the outside
Municipality type

The number of hospital beds per
1,000 persons

Yes(n = 85,
21.4%)
n (%) or mean ± SD

94 (43.5) <.001b** 152 (38.2)

21 (10.0) <.001b**

Fulltime 239 (62.2) 121 (69.1) 118 (56.5)

30 (16.8)

42 (25.0)

Staff nurse 130 (33.9)
97 (25.3)

50 (28.6)

71 (18.5)

Yes

Yes

Aging rateb

p valueAll

Women 363 (94.5) 169 (96.6) 194 (92.8).108375 (94.5) 79 (92.9) 296 (94.9)
Years 45.7 ± 6.8 47.2 ± 6.2 44.5 ± 7.0 <.001c** 45.8 ± 6.4 45.7 ± 5.9 45.8 ± 6.5

Inpatient ward

SD = standard deviationaOrdinance-designated city, includes the 23 special wards.
b
Chi-square testcWelch’s t-testdFisher’s exact testeMann–Whitney U test
*p < .05, **p < .01

Community
characteristics

No(n = 209)n (%) or mean ± SD

Yes(n = 175,
45.6%)

Having conducted collaborative visits

Having conducted collaborative visits
All

Cancer palliative care (n = 397)

Wound, ostomy, and continence care(n = 384)

Having long-term nursing facility

Hospital
The number of beds
characteristics Having consultation counter for thecommunity
Having home care nurse department

Working hours as specialist nurse

Specialist
Fulltime/parttime as specialist nurse
nurses’ work Participation in community-based
characteristics multidisciplinary gatherings
Participation in the seminars in thecommunity
Having specialist nurse-led clinic

Department of work

Training for specific medical
procedures (Tokutei kooi kensyu)
Work position

Demographic Sex
characteristics Age

Variables

Table 1. Participants’ characteristics (n = 1,027).

https://doi.org/10.53044/jinr.2021-0011
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https://doi.org/10.53044/jinr.2021-0011

Table 2. Factors related to collaborative visits by multiple logistic regression analysis.
WOC
n = 384
Variables

95% CI

p value

AOR

1.04 1.01–1.08 .034*
2.76 1.49–5.09 .001**.97

1.81 1.07–3.07 .027*.82 .43–1.55 .543
1.41
.77–2.61 .269
1.05
.62–1.78 .858
1.39

.77–2.53

1.36
.68
1.10

AOR

LL–UL
Demographic
characteristics

Specialist
nurses’ work
characteristics

Hospitalcharacteristics

Community
characteristics

Age
Training for specific procedures(Tokutei kooi kensyu) a
Work positionb
Department of workc
Fulltime/parttime as specialist nursed
Participation in community-based
multidisciplinary gatheringsa
Participation in the seminars in thecommunitya
Working hours as specialist nursee
The number of bedsf
Having consultation counter forcommunitya
Having home care nurse departmenta
Having long-term nursing facilitya
Advertising specialist nurses’
practice in the communitya
Municipality typeg
Aging rate
The number of hospital beds per
1,000 person

Cancer palliative caren = 397
95% CI
LL–UL.93–1.01

Care of chronic diseasen = 246

p value

AOR

.114

.96

95% CI
LL–UL

p value.90–1.03.227

2.62 1.40–4.89 .003**.90.50–1.62 .736

1.91 .87–4.20.58 .27–1.28

.109
.178

1.36

.79–2.32.45 .21–.97.040**.278

2.31.89–6.00 .086

.70–2.61 .363
.40–1.14 .143
.68–1.77 .701

1.57

.89–2.77

.121

1.54

.89–2.66

.120

.264

2.58 1.50–4.47 .001**.78.42–1.46 .443
1.61
.78–3.32 .200

1.90 1.03–3.54 .041*
1.63 .82–3.25 .163
1.24 .57–2.69 .588

.58
1.05
.92

.59
1.10

.33–1.01 .056
.99–1.12 .120
.86–.98 .013*

2.16 1.06–4.42 .034*
2.05 .99–4.26.055
2.08 1.01–4.27 .047*
2.52

1.25–5.07

.010*

1.68

.52–5.46.390.29–1.18 .135
1.02–1.18 .012*

Dependent variable is having conducted the collaborative visits, yes = 1, no = 0.
WOC = Wound, ostomy, and continence care; AOR = adjusted odds ratio; CI = confidence interval; LL = lower limit; UL = upper limita
Yes = 1, no = 0bHead nurse and vice-head nurse = 1, staff nurse = 0cInpatient ward = 1, others = 0dFulltime as specialist nurse = 1, part time = 0
e
1 day/ week or more = 1, <1 day/ week = 0
fLarge (400–) = 1, small or medium (0–399) = 0g
Ordinance-designated cities = 1, other cities = 0*p < .05, **p < .01

1.02-1.18) were significantly associated with collaborative
visits. Although bivariate analyses showed that the completion of training for specific medical procedures was statistically significant in the cancer palliative care group, it was
not included in the logistic regression analyses because thecorresponding sample was very small (n = 8). For SNs specializing in care for chronic diseases, lower participation incommunity-based multidisciplinary gatherings (AOR, .45;
95% CI, .21-.97), the number of working hours as SNs(AOR, 2.16; CI, 1.06-4.42), working in a hospital with acommunity consultation counter (AOR, 2.08; 95% CI, 1.014.27), and working in a hospital with a home care nurse department (AOR, 2.52; 95% CI, 1.25-5.07) were significantly
associated with collaborative visits (Table 2).

6 of 9Discussion
This study investigated the current practice of collaborative
visits by hospital-based SNs. This study is believed to be thefirst study to describe these visits from the perspective of
SNs and by linking their descriptions to hospital and community statistics.
A significant number of SNs reported that they provide
collaborative visits. Almost half of WOC nurses reported
conducting collaborative visits. Nearly one in five SNs specializing in care for chronic disease reported conducting collaborative visits, even though no medical reimbursement
available for their visits was observed. These results indicate
the growing interest of hospitals and nurses in Japan in the
recent promotion of advanced practice by specialists inhomecare settings. The rate of WOC nurses who had con-

https://doi.org/10.53044/jinr.2021-0011

ducted collaborative visits in a 2016 study was less than athird of the total (Kaitani et al., 2017). Thus, the number ofcollaborative visits seems to be increasing, probably reflecting the gradual spread of this system. For other societies
facing similar challenges of overcoming health systems centered on acute care to ensure optimal homecare, this study’s
findings are noteworthy in the establishment and promotionof advanced practice nursing for homecare clients.
Several characteristics regarding SNs’ working conditions
were revealed to be associated with collaborative visits. The
number of working hours as SNs was related to the care forchronic disease nurses conducting collaborative visits. Previous studies have reported that SNs’ lack of time due to busy
work conditions limits their practice (Clevenger et al., 2020;
Riordan et al., 2017). Even though SNs would like to conduct collaborative visits, they may not be able to do so due
to time constraints. Working in a managerial role was related to collaborative visits conducted by SNs belonging to
WOC and cancer palliative care groups. This may mean that
nurses in managerial roles have more discretion in theirwork hours and can provide home visits. Moreover, SNs
working as staff are usually engaged in regular staff functions and may have limited discretion and opportunities to
use their specialist expertise (Riordan et al., 2017). Bothworking hours and working status depend on organizational
policy, suggesting the importance of organizational support
for SNs’ collaborative visits.
Training completion for specific medical procedures(tokutei koi kensyu) was associated with collaborative visits
for nurses specializing in WOC. A similar trend was also
observed in the cancer palliative care group. An earlier study
has reported that many hospital nurses are unwilling to practice in homecare settings because of their lack of homecare
expertise (Varley et al., 2020). Completion of training forspecific medical procedures may have enabled nurses to become confident enough to apply their skills in homecare settings. One of the six specialty packages of the training is
aimed at homecare (Ministry of Health, Labour and Welfare,n.d.), although it is unlikely that SNs participated in the
training as a result of providing collaborative visits giventhat the collaborative visit is only a small part of their entire
activities as hospital SNs. This training started in 2015 (Ministry of Health, Labour and Welfare, 2015), and more studies are needed to examine its impact on SNs’ practice behaviors.
SNs in the care for chronic disease group who participated in community-based multidisciplinary gatherings wereless likely to conduct collaborative visits. This result is contrary to previous studies (McDonnell et al., 2015; Restrepo
et al., 2001). Without medical reimbursement for collaborative visits, SNs in the chronic disease group may complete
their collaboration with community professionals in thosegatherings rather than conduct direct visits. However, SNs

JINR 2023, 2(1), e2021-0011

may need to see clients directly to properly understand theircondition (McDonnell et al., 2015). It may thus be necessary to expand medical reimbursement to cover chronic disease care.
Certain hospital characteristics were associated with collaborative visits. Hospitals with a community consultation
counter were associated with collaborative visits among thecare for chronic disease group. To bridge the existing gap
between hospital and home care, a system for care coordination is required and may play an important role (Mackavey,2016). Similarly, more collaborative visits were conductedacross all groups associated with hospitals with a homecare
nurse department. Nurses have easier access to and can easily collaborate with colleagues in a hospital, whereas geographical distance separates hospital and homecare andmakes it more difficult (Varley et al., 2020).
Furthermore, some community characteristics were related
to collaborative visits in WOC and cancer palliative caregroups. SNs who worked in municipalities with a high aging rate were more likely to provide collaborative visits,
while those who worked in municipalities with a high number of hospital beds per 1,000 population were less likely to
conduct collaborative visits. These results suggest that collaborative visits are influenced by the relative availability ofcommunity medical resources, and citizens may need more
homecare services in such regions. Fewer hospital beds per
capita are related to the utilization of homecare nursing
services (Nakanishi et al., 2017), and homecare needs arehigher in depopulated and aging areas (McDonnell et al.,2015). Thus, more integrated care between the hospital andthe community seems to be necessary for municipalities
with higher aging rates and where medical services are relatively scarce.
This study has three limitations. First, it had a relatively
low response rate. The response rate varied depending on
the specialties of CNSs and CNs. The resulting overall response rate became lower because specialties that have aweak affinity with homecare, e.g., intensive care, were included. The average age of participants in this study, about
45.5 years, is almost the same as that of the national registryof SNs. Moreover, the rate of staff nurses in the current
study was lower than that in the registry data, suggestingthat the current sample over-represents SNs in managerial
roles. This should be considered when interpreting the study
results. Second, individual collaborative visits could not be
investigated and their details elucidated, something whichshould be evaluated in future studies. Finally, this study was
conducted as a cross-sectional survey; therefore, causal relationships between collaborative visits and their related factors could not be determined.
Despite these limitations, this study is the first nationwide
investigation that describes collaborative visits made by hospital SNs from the perspective of those SNs and by linking
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their descriptions to hospital and community statistics. The
results underline the importance of organizational and policy
support as well as individual SNs’ efforts to promote collaborative visits in the community. Additionally, hospital organizations may also need to consider the specific needs ofeach community to better serve them. In the context of exploring a new system to provide nursing service, collaborative visits under various strategies considering organizationaland community factors are expected to offer advanced andspecialized care to clients at home. In the future, identifying
the mechanisms of collaborative visits and their effects
based on client outcomes is necessary. More studies areneeded to identify the barriers and facilitators of such visits
to further develop an effective practice model of SNs’ collaborative visits in the community.
Author Contributions
Aruha Masuda designed and conducted the study, analyzed
and interpreted the data, and prepared the manuscript.
Mariko Sakka interpreted the data and reviewed the manuscript. Satomi Kitamura interpreted the data and reviewed
the manuscript. Ayumi Igarashi interpreted the findings andcritically reviewed the manuscript. Maiko NoguchiWatanabe interpreted the findings and critically reviewed themanuscript. Akiko Araki coordinated the research, interpreted the findings, and critically reviewed the manuscript.
Noriko Yamamoto-Mitani coordinated the research, interpreted the findings, and critically reviewed the manuscript.
Declaration of Conflicting Interests
The authors have no conflict of interest to disclose.
Ethical Approval
This study was approved by the research ethics committeeof the Graduate School of Medicine at the University of Tokyo [No. 2019050NI-(2)], Tokyo, Japan.
Funding
This work was funded by the Geriatric Health Promotion
Project of the Ministry of Health, Labour and Welfare, 2019.
Informed Consent
Informed consent was obtained from all participants involved in this study.
Note
Current affiliation of Maiko Noguchi-Watanabe: Departmentof Home and Palliative Care Nursing, Tokyo Medical and
Dental University, Tokyo, Japan
Current affiliation of Akiko Araki: Department of Child
Health Nursing, Faculty of Nursing, Toho University, Tokyo,Japan
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Original Research

Development of a reliable and valid cancer-related communication scalefor use between breast cancer survivors and their adolescent children
Rei Oshiro, PhD, RN1,2 , Masahiko Tanabe, PhD, MD3 , Keiichiro Tada, PhD, MD4 , Junko Takei, MD5 ,Hideko Yamauchi, MD5 , and Kiyoko Kamibeppu, PhD, RN, FAAN1,6
1

Department of Family Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, Universityof Tokyo, Tokyo, Japan, 2Department of Nursing, School of Nursing, Hyogo Medical University, Hyogo, Japan,
3
Department of Breast and Endocrine Surgery, The University of Tokyo Hospital, Tokyo, Japan, 4Department ofBreast and Endocrine Surgery, Nihon University Itabashi Hospital, Tokyo, Japan, 5Department of Breast Surgical
Oncology, St. Luke’s International Hospital, Tokyo, Japan, and 6General incorporated association Quality of Life
Research Center for Children and Family, Tokyo, Japan

Abstract
Objective: This study aimed to investigate the contents of communication between breast cancer survivors andtheir adolescent children and to develop a reliable and valid communication scale on maternal breast cancer.
Methods: The items were extracted from expert and cognitive interviews. The pilot test comprised self-reportquestionnaires distributed among 97 adolescents aged 12-18 years whose mothers were diagnosed with breast
cancer; a retest was conducted on 34 adolescents. Validity was confirmed by testing factorial, known-groups, convergent, and discriminant validity. Reliability was confirmed by measuring internal consistency and test-retest reliability. Results: The mean age of the participants was 14.8 ± 2.0 years, and 51 (52.6%) of them were female. The
average age of being informed about maternal breast cancer was 12.5 ± 2.7 years. Confirmatory factor analysis
supported 14 items and a 3-factor model, which included expression of negative feelings (first factor), sharing information about breast cancer (second factor), and relationship with the mother (third factor): χ2/df = 1.21,
goodness-of-fit index = .892, comparative fit index = .973, root mean square error of approximation = .047, andAkaike information criterion = 154.074. For convergent validity, the family adaptability, partnership, growth, affection, and resolve scale confirmed weak correlations for the total, second factor, and third factor scores. Cronbach’s
α for the total, first, second, and third factors were .863, .764, .882, and .810, respectively. Conclusions: The reliability and validity of the communication scale were confirmed. The scale can help nurses understand and evaluate mother-adolescent communication and devise interventions for facilitating informative, effective, and open discussions regarding maternal breast cancer.
Keywords
adolescent, cancer survivors, communication, family nursing
JINR 2023, 2(1), e2021-0009

Introduction
In Japan, approximately 92,000 women were diagnosed withbreast cancer in 2017, and the prevalence of this disease is
rapidly increasing worldwide (Cancer Information Service,2021). The first sign of breast cancer occurs when a woman

Correspondence: R. Oshiro. Email: re-oshiro@hyo-med.ac.jp
Received: July 19, 2021, Accepted: June 1, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 9JINR 2023, 2(1), e2021-0009

is in her late 40s (Cancer Information Service, 2021). Thisis commonly the child-rearing stage, and many breast cancer
survivors have children below the age of 18. Previous studies have demonstrated that children of mothers with breast
cancer reported the adverse effects of the disease on their
physical, emotional, and psychological health, including
anxiety, depression, fear, distress, anger, fear of being alone,
sleeping difficulties, and headaches (Cappelli et al., 2005;
Chan et al., 2020; Edwards et al., 2008; Visser et al., 2004;
Walczak et al., 2018).
Given the risk of psychological and behavioral problems,
adequate communication regarding breast cancer between
breast cancer patients and their adolescent children is essential to avoid these negative effects (Cho et al., 2015). Fitch
and Abramson (2007) found that adolescent children aged
12-18 years who did not receive adequate communication
regarding maternal breast cancer experienced isolation, fear,
and anxiety. In addition, previous studies investigating adolescent children of cancer patients have found that effective
communication reduced post-traumatic stress symptoms andanxiety levels (Huizinga et al., 2005; Nelson et al., 1994). A
qualitative study investigating 11 children whose parents
were diagnosed with cancer demonstrated that most participants wanted to communicate with their parents about cancer (Kennedy & Lloyd-Williams, 2009). However, breast
cancer survivors find it difficult to talk about cancer with
their children. Reasons for the lack of communication include the mothers’ desire to protect their children from distress, the wish to retain the normalcy of their usual lives asmuch as possible, and management of their sense of uncertainty related to the prognosis (Asbury et al., 2014; Stiffler
et al., 2008). According to a qualitative study, children aged
8-18 years, whose mothers were diagnosed with breast cancer, have a basic knowledge of the cancer and its treatment(Huang et al., 2017). They acquire this knowledge not only
from their families but also from school, books, and online
resources. However, their understanding of the cancer is notalways accurate. Adolescents often ask many questions owing to their intellectual curiosity. However, at this stage ofdevelopment, they are reluctant to talk to their parents.
Moreover, they not only understand cancer as a disease, butthey tend to associate the word “cancer” with death, causing
them to become overly anxious and upset (Fitch & Abramson, 2007). Appropriate communication with adolescents
about maternal breast cancer can help them understand anddeal with the disease, reduce their anxiety and suffering, andcontribute to maintaining a stable daily life.
Nurses should promote appropriate communication regarding cancer between mothers and their adolescent children. Before developing an intervention to support cancerrelated communication, developing a scale that would reliably evaluate how adolescents perceive communication (including its contents and frequency) about maternal breast
2 of 9https://doi.org/10.53044/jinr.2021-0009

cancer with their mothers is crucial. However, as far as weknow, there are no instruments to measure cancer-related
communication between cancer survivors and their adolescent children. Although most previous studies used a parentadolescent communication scale to assess cancer-related
communication between both parties (Barnes, 1982; Cho etal., 2015; Huizinga et al., 2005), they did not measure specific factors associated with cancer, including information
about the details of cancer (i.e., stage, symptoms, treatment,
and side effects) and the respondents’ feelings about it. For
these reasons, our study aimed to (1) understand the contents of cancer-related communication and (2) develop a reliable and valid scale to measure communication between
breast cancer survivors and their adolescent children.

Materials and Methods
This study consisted of item extraction, cognitive interviews,
and a pilot test.
Item Extraction
We extracted 19 items from previous studies about cancerrelated communication scales (Kornblith et al., 2006) andwebsites for cancer survivors and their families (CancerCare,
2018; Cancer.Net, 2018). We conducted expert interviews
with 10 participants: 4 doctors, 3 nurses (pediatric, cancer,
and breast cancer nurse specialists), and 3 managers of cancer patient associations. From these interviews, two more
items (items 20 and 21) were added, and a four-point Likert
scale, ranging from strongly disagree to strongly agree, wasapplied. We confirmed the surface and content validity of
the items. Because the target participants of this study wereadolescents, the sentences of the items were modified to use
simpler words to make the questions more comprehensible.
Cognitive Interviews
To examine the content validity of the 21 items, we conducted cognitive interviews with 9 adolescents aged 12-18
years whose mothers were diagnosed with cancer. First, one
researcher measured the time required to complete the questionnaire, which ranged from 1 to 5 min (average, 3.25
min). The researcher then interviewed the adolescents about
their thoughts on maternal cancer and noted if the questionnaire’s content evoked any negative feelings. The participants did not report experiencing any such feelings due tothe words used or the content of the questionnaire. Aftercompleting this process, the final scale was developed.
Pilot Test
Participants
We recruited participants from three hospitals and two cancer patient associations from February to September 2019.
The inclusion criteria were as follows: (1) adolescents agedhttps://doi.org/10.53044/jinr.2021-0009

12-18 years whose mothers were diagnosed with breast cancer, (2) participants with the ability to answer the questionnaire in Japanese, and (3) consent to participate provided byboth the adolescents and their guardians. We excluded thoseadolescents whose guardians considered them unable to participate due to physical or psychosocial disabilities.
Procedure
The researchers explained the study purpose and proceduresto the breast cancer survivors whose children met the inclusion criteria. The researchers then asked them to provide informed consent-related documents and questionnaires totheir children. Each child answered the questionnaire and returned it to the researchers via mail.
The participants were asked if they wanted to participate
in the second survey, which was conducted 2 weeks after
the first one to verify retest reliability. We gifted a ballpoint
pen to the participants as a token of appreciation for their
participation.
Measurement
A cancer-related communication scale to be used between
breast cancer survivors and their adolescent children was developed based on the results of the item extraction and cognitive interviews. This scale contained 21 items rated on a
4-point Likert scale, with a higher score indicating appropriate communication about breast cancer between breast cancer survivors and their adolescent children.
Family functioning was evaluated using the family adaptability, partnership, growth, affection, and resolve (APGAR)
scale (Kokubu & Kamibeppu, 2013; Smilkstein, 1978). A
higher score indicates higher satisfaction with family support(competence). Cronbach’s α for this scale in the present
study was .776.
The demographic data of the participants included theirgender, age, and educational level. We also collected data
regarding the age at which they were notified about maternal breast cancer; the presence of peer support, trauma, andsubjective stress due to maternal breast cancer; and an experience that was more stressful than maternal cancer.
Statistical Analysis
Descriptive statistical analysis was conducted on the demographic characteristics of the participants; means and standard deviations were calculated for continuous variables, andratios were calculated for discrete variables. The validity ofthe scale was confirmed by verifying factorial, convergent,and discriminant validity. Through an exploratory factor
analysis (EFA), the number of factors was determined using
parallel analysis. A confirmatory factor analysis (CFA) was
conducted to confirm the goodness-of-fit. The χ2/df,
goodness-of-fit index (GFI), comparative fit index (CFI),
root mean square error of approximation (RMSEA), andAkaike information criterion (AIC) were used as goodnessof-fit indices.

JINR 2023, 2(1), e2021-0009

To confirm convergent validity, we used the Family APGAR family functioning scale. Appropriate communicationin the family is associated with better family functioning(Ghandpazi et al., 2020). We hypothesized that the correlation between the cancer-related communication scale and theFamily APGAR family functioning scale is positive. Spearman’s rank correlation coefficients between the total andsubscale scores of cancer-related communication scale andthe scores of Family APGAR family functioning scale were
calculated. Reliability was confirmed by verifying internalconsistency using Cronbach’s α, and test-retest reliability
was verified using intraclass correlations (ICC).
In addition, we determined whether the scores of thecancer-related communication scale are affected by demographic characteristics. Regarding gender and the presenceor absence of a sibling, Welch’s t-test was conducted. Furthermore, Spearman’s rank correlation coefficient between
the scores of the cancer-related communication scale andage were calculated.
IBM SPSS 25.0 for Windows (SPSS, Chicago, Illinois,
USA) and IBM SPSS Amos version 25.0 (SPSS, Chicago,
Illinois, USA) were used for statistical analysis, and p < .05(two-tailed) was considered significant.
Ethical Considerations
This study was approved by the Ethics Review Committeeof the University of Tokyo, School of Medicine [No. 12079(1)]. Both the adolescents and their guardian(s) provided
written informed consent.

Results
Participant Demographics
We distributed the questionnaires to 129 breast cancer survivors. A total of 107 adolescent children of breast cancer survivors submitted their informed consent forms and questionnaires (response rate, 82.9%). After excluding questionnaires
with missing values, 97 responses were finally recorded (effective response rate, 90.7%). The retest questionnaires weresent to 45 participants, and 35 responses were obtained (return rate, 77.8%). Responses with missing values were excluded, and 34 responses were finally included in the retest
data (effective response rate, 97.1%).
The mean age of the participants was 14.8 ± 2.0 years,
and 51 (52.6%) of them were female. The average age ofbeing informed about maternal breast cancer was 12.5 ± 2.7
years. A total of 38 (39.2%) participants experienced trauma
due to maternal breast cancer, whereas 34 (35.1%) experienced more stress due to other factors, such as trouble withfriends at school, parent-child relationship, and entrance examinations (Table 1).

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Table 1. Participants’ characteristics (n = 97).
Mean ± SD [range] or n (%)
Demographics
Age (years)
Gender
Educational level

Male
FemaleJunior high school
High school
Other

Experiences related to maternal breast cancer
Age at the time of diagnosis notification (years)
Years passed since notification
Peer support a
Trauma due to maternal breast cancer
Subjective stress due to maternal breast cancer bStressful experience greater than maternal breast cancer

Yes
No
Yes
No
Yes
No

14.8 ± 2.0
46
51
53
37
7

[12–18](47.4)(52.6)(54.6)(38.1)(7.2)

12.5 ± 2.7
2.2 ± 2.3
11
86
38
58
2.4 ± 1.1
34
53

[7–18][0–9](11.3)(88.7)(39.2)(60.8)[1–5](35.1)(64.9)

Notes: Missing values were excluded; aFriends whose parents were diagnosed with cancer, b1 =not stressful at all, 5 = very stressful; SD = standard deviation.

Validity
Factorial Validity
Based on the parallel analysis, three factors were extracted.
We conducted an EFA using the principal factor method andpromax rotation. Furthermore, we selected items based on
factor loadings of !
0.4. Because items 2-5 included content
regarding communication and expression of negative feelings about maternal breast cancer, such as I cannot talkabout cancer with my mother because I get too upset (cry,get angry, panic) (inverted term) and I do not tell my motherhow scared I am because she has breast cancer (invertedterm), this first factor (F1) was named “expression of negative feelings.” Items 6-16 included content regarding communication and shared information about maternal breast
cancer, such as My mother explains her treatment plan andhow it will affect my life in words that I can understand andMy mother and I talk about our worries about whether hertreatment will work. This second factor (F2) was named“sharing information about breast cancer.” Items 19-21 included content regarding mother-adolescent relationship,such as I feel trusted by my mother. This third factor (F3)
was named “relationship with mother.” Items 1, 7, 17, and18 were deleted as they did not fit within the purview of
any factors (Table 2).
A CFA was conducted on the 17 items and 3-factor
model of the scale. The GFI did not show sufficient values
in this model. Therefore, three items (5, 6, and 15), which
had a factor loading of .5 or less, were excluded. After confirming that the GFI showed a good value, a 14-item 34 of 9

factor model was adopted: χ2/df = 1.21, GFI = .892, CFI =.973, RMSEA = .047, and AIC = 154.074 (Table 3, Figure1, 2).
Convergent Validity
The total score and F2 “sharing information about breast
cancer” and F3 “relationship with mother” scores were significantly correlated with the score of the Family APGAR
scale (Table 4).
Reliability
Regarding internal consistency, Cronbach’s α for the total, F
1, F2, and F3 scores were .863, .764, .882, and .810, respectively. In the retest analysis, the interval between testing
and retesting was 16-53 days (average, 28.3 days) for the 34
respondents. The ICC was .748 for the 14 items and .618,.756, and .794 for F1, F2, and F3, respectively (Table 5).
Demographics Related to the Scores of the Cancer-related
Communication Scale
For the total score, the mean score (45.2) of the female
group was significantly higher than that of the male group(41.7; p = .02). Similarly, the mean score of F2 “sharing information about breast cancer” was significantly higher inthe female group (23.8) than in the male group (21.0; p =.02). Regarding the presence or absence of sibling, the absence group tended to have higher scores. For the score of F
3 “relationship with mother,” the mean score (10.9) of theabsence group was significantly higher than that of the presence group (9.8; p = .03; Table 6). No significant correlation
was observed between the total and subscale scores and age.

https://doi.org/10.53044/jinr.2021-0009

JINR 2023, 2(1), e2021-0009

Table 2. Exploratory factor analysis: principal factor method and promax rotation (n = 97).
#

Items

F1

F2

F3

.926

.149

−.049

.691
.568
.425

.000
.008
.091

.036
−.072
.091

.106
−.005

.828
.810

−.254
−.010

.030
−.074
−.033

.758
.680
.653

−.008
.035
.109

.051
.121
−.080
.084
−.303

.613
.597
.596
.445
.431

−.006
.122
.133
.040
.087

Relationship with mother (F3) Cronbach’s α = .810
19
My mother still listens to me, even after her cancer diagnosis.
20
I am satisfied with the communication I have had with my mother since I learned she had cancer.
21
I feel trusted by my mother.

.059
.117
−.043

−.077
.140
.207

.836
.706
.604

1
17
18
7

My mother understands how I feel about her having cancer.
When it comes to cancer, I only tell my mother what she wants to hear.
My mother does not ask me how her having cancer affects my life.
I confide in my friends more than my mother about her having cancer.

−.116
.342
.280
−.261

.308
-.336
.063
.237

.134
.068
.175
−.203

% Variance explained by factor

11.7

26.1

4.8

Expression of negative feeling (F1) Cronbach’s α = .664
4 ☆ My mother does not talk about cancer with me because she does not want me to get upset (i.e., cry, getangry, panic).
3 ☆ I cannot talk about cancer with my mother because I get too upset (i.e., cry, get angry, panic).
2 ☆ My mother gets upset when I talk about my feelings about her having cancer.
5 ☆ I do not tell my mother how scared I am because she has cancer.
Sharing information about breast cancer (F2) Cronbach’s α = .880
8
We discuss/discussed what treatment she is getting.
10
I talk with my mother about how cancer treatment changed her body (e.g., removal of breast, hair loss,
dietary changes).
14
My mother explains her treatment plan and how it will affect my life in words that I can understand.
12
I talk with my mother about what to do if her condition becomes significantly worse.
11
I talk with my mother about how I feel about the way cancer treatment changed her body (e.g., removal of breast, hair loss, dietary changes).
9
My mother and I talk about our worries about whether her treatment will work.
16
When I ask about cancer, she provides gentle and honest answers.
13
I participate in my mother’s care (e.g., nurse her, go to the hospital).
6
I can tell my mother anything that is on my mind about her having cancer.
15
I know when my mother wants to talk about cancer and when she does not.

☆
☆

Notes: ☆ inverted terms; F1 = First factor, expression of negative feelings; F2 = Second factor, sharing information about breast cancer; F3 = Third
factor, relationship with mother.

Table 3. Comparison of goodness-of-fit index (n = 97).

Model 1 (17 items)
Model 2 (14 items)

2

χ /df

GFI

CFI

RMSEA

AIC

1.36
1.21

.849
.892

.936
.973

.061
.047

233.251154.074

Notes: GFI = goodness-of-fit index, CFI = comparative fit index, RMSEA = root mean square error of approximation, AIC = Akaike information criterion; Model 2: Excluded items 5, 6, and 15 from Model 1.

Discussion
This study demonstrated the contents of cancer-related communication and developed a reliable and valid scale tomeasure cancer-related communication between breast cancer survivors and their adolescent children. The results ofthis study indicated that cancer-related communication comprised 14 items and a 3-factor structure, including “expression of negative feelings,” “sharing information about breast
cancer,” and “relationship with the mother.” Moreover, theresults of internal consistency and test-retest reliability weresatisfactory.
As a result of the EFA, a three-factor structure was extracted. The main contents of communication about cancer
were expression and sharing of feelings as well as provisionand sharing of information (Barnes et al., 2000; Fitch &Abramson, 2007; Huang et al., 2017; Kennedy & LloydWilliams, 2009; Semple & McCance, 2010). These contents
were included in F1 “expression of negative feelings” and F
2 “sharing information about breast cancer,” respectively. F3“relationship with the mother” included contents regarding
the relationship with the mother, and two out of three items
were added based on expert interviews. Furthermore, thisfactor is essential for indicating whether the motheradolescent relationship was well established through communication, from the time the mother was diagnosed withbreast cancer to the present. The scale had to be reduced
from 21 to 14 items to ensure optimal model goodness-of-fit
by CFA. However, the final 14 items cover the indispensable
elements for effective communication, serving as a reliablemeasure in communication about maternal cancer.
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e2e3

https://doi.org/10.53044/jinr.2021-0009

Item 2Item 3

.28

.67

.94

.97

e4

Item 4e5Item 5e6Item 6.19e8Item 8

.45

.43

e9

Item 9

.32

.67

e10

Item 10

.70

.57
.84

e11

Item 11

.58

.19

.20

−.39

.53

.45

e12

Item 12.35 e13

Item 13e14

Item 14e15

Item 15e16

Item 16e19

Item 19

e20
e21

Item 20
Item 21

.41
.40
.62
.20

Expression ofnegative feelings

.43

.05

.76
.64
.63

Sharing information
about breast cancer

.20

.79
.45
.66

.44

.60

.55
.74
.49

.74
.86
.70

Relationshipwith motherFigure 1. 17-item three-factor analysis model.
e2e3

Item 2Item 3e4

Item 4e8

Item 8e9e10

Item 9Item 10.21e11

Item 11e12

Item 12.37 e13

Item 13e14

Item 14e16

Item 16e19

Item 19−.42

e20

Item 20

e21

Item 21

.31

.56

.51

.71

.82

.91

.45
.32

.04

.67
.57

.72

.85

.57

.76

.39

.63

.38

Sharing information
about breast cancer

.20

.61
.80

.64

.66
.60

.43

.55
.75
.49

.74
.86
.70

Figure 2. 14-item three-factor analysis model.

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Regarding convergent validity, the total score and F2 andF3 subscale scores had weak correlations with Family APGAR. Previous studies have demonstrated that effective
communication in the family improves family functioning(Ghandpazi et al., 2020). Our hypothesis was supported byresults of this study, except that for the subscale of F1. F1comprised the expression of negative emotions. Based on
the characteristics of the family (Wright & Leahey, 2012),
when the breast cancer survivor fails to accept the emotionsof the adolescent about maternal breast cancer, she experiences pain and depression. This situation causes the adolescent to also experience guilt and pain. These feelings may
increase and create a vicious cycle. A breast cancer survivor

and her adolescent child may unintentionally hurt each otherwhen the adolescent expresses his/her negative emotions
about maternal breast cancer, thus leading to impaired family functioning. Therefore, no correlation between F1 andfamily functioning was observed.
Regarding the demographics associated with cancerrelated communication, the female group obtained higher
mean total and F2 scores than the male group. Previous
studies have demonstrated that male family members hesitate to talk about breast cancer openly because breasts areassociated with sexuality and femininity (Fitch & Allard,2007). In addition, men aged 12-18 years are sexually sensitive; they may be less likely to share information about
symptoms, treatment, progress, and side effects of maternalbreast cancer with their mothers. The absence of siblinggroup tended to have higher scores than the presence of sibling group. Adolescent children without siblings may havemore time for one-on-one communication with their mothers. However, further research is needed to elucidate the factors that influence cancer-related communication.

Table 4. Convergent validity of thecommunication scale (n = 97).
Family APGAR
Total (14 items)
F1 (3 items)
F2 (8 items)
F3 (3 items).341**−.017.345**.262**

Implications for Nurses
For breast cancer survivors/patients, one of the most crucial
areas of concern is communicating with their adolescentchildren about breast cancer. Breast cancer survivors/patientsrequire support from their healthcare professionals to beable to effectively communicate with their adolescent children (Sinclair et al., 2019). This cancer-related communication scale can help nurses understand and evaluate motheradolescent communication about maternal breast cancer.
Furthermore, nurses can devise interventions for facilitating
informative, effective, and open discussions regarding maternal breast cancer by using this scale.

Notes: APGAR = adaptability, partnership, growth, affection, and resolve; F1 =First factor, expression of negative feelings; F2 = Second factor, sharing information about breast cancer; F3 = Third factor, relationship with mother. ** p < .01

Table 5. Internal consistency and test–retest reliability of thecommunication scale.

Total (14 items)
F1 (3 items)
F2 (8 items)
F3 (3 items)

Cronbach’s α (n = 97)

ICC (n = 34)

.863
.764
.882
.810

.748
.618
.756
.794

Limitations
This study has some limitations. First, the study participants(adolescents) were given the questionnaires by breast cancer
survivors, which could indicate that they had a good andopen relationship with them. Therefore, adolescents who had

Notes: ICC = Intraclass correlation coefficients; F1 = First factor,
expression of negative feelings; F2 = Second factor, sharing information about breast cancer; F3 = Third factor, relationship with mother.

Table 6. Comparison of the scores of cancer-related communication scale by gender and the presenceor absence of a sibling.
GenderFemale(n = 51)

Total (14 items)
F1 (3 items)
F2 (8 items)
F3 (3 items)

SiblingMale(n = 46)

Absence(n = 22)

Presence(n = 75)

Range

Mean

SD

Mean

SD

p

Mean

SD

Mean

SD

p

14–56
3–12
8–32
3–12

45.2
11.0
23.8
10.4

6.2
1.2
5.2
1.7

41.7
11.0
21.0
9.6

8.4
1.7
6.5
2.4

.02
.93
.02
.08

45.8
11.3
23.7
10.9

6.6
0.9
5.7
1.4

42.9
11.0
22.1
9.8

7.6
1.6
6.1
2.2

.10
.37
.28
.03

Notes: SD = standard deviation; F1 = First factor, expression of negative feelings ; F2 = Second factor, sharing
information about breast cancer; F3 = Third factor, relationship with mother.

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problems communicating with the survivors may have been
unintentionally excluded, thus introducing a selection bias.
Second, EFA and CFA were conducted using the same datato confirm factor validity. In the future, the validity of factors will need to be confirmed using different data. Third,
the cancer-related communication scale in this study does
not include items related to positive aspects, such as awareness and positive emotions experienced by a mother diagnosed with breast cancer, including coping and health management efforts. Future studies could measure cancer-related
communication between breast cancer survivors and theiradolescent children more accurately by considering the
aforementioned aspects.
Conclusion
This study developed a valid and reliable scale to evaluate
and assess cancer-related communication between breast
cancer survivors and their adolescent children. It is proposedthat the findings of this study could help devise psychosocial interventions to support breast cancer survivors andtheir families.
Acknowledgments
We are deeply grateful for the valuable comments and support on this research from Yohei Nishiguchi, general incorporated association Cancer Parents. We are also thankful tothe participants and staff for their cooperation with thisstudy.
Author Contributions
R.O. and K.K. contributed to the conception and design ofthis study; R.O., M.T., K.T., J.T., and H.Y. conducted datacollection; R.O. performed the statistical analysis anddrafted the manuscript; M.T., K.T., J.T., H.Y., and K.K.
critically reviewed the manuscript and supervised the wholestudy process. All authors read and approved the final
manuscript.
Declaration of Conflicting Interests
The authors declare that there are no conflicts of interest.
Ethical Approval
This study was approved by the Ethics Review Committeeof the University of Tokyo, School of Medicine [No. 12079(1)].
Funding
This work was supported by a grant-in-aid of the Yamaji Fumiko Nursing Research Fund and a grant-in-aid for EarlyCareer Scientist awarded to Rei Oshiro (grant number 21K
17382).

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Original Research

Mental health status of public health nurses and its related factors under
the coronavirus disease 2019 pandemic in Japan
Karen Tsuruda, MSN1 , and Yoko Hatono, PhD2
1Master’s Course in Nursing, Department of Health Sciences, Graduate School of Medical Sciences, Kyushu
University, Fukuoka, Japan, and 2Department of Health Sciences, Faculty of Medical Sciences, Kyushu University,
Fukuoka, Japan

Abstract
Objective: The purpose of this study is to investigate the mental health status of public health nurses (PHNs) inpublic health centers (PHCs) and to clarify its related factors during the coronavirus disease 2019 (COVID-19)
pandemic in Japan. Methods: Participants were 1,320 full-time PHNs in PHCs, and self-administered structured
questionnaire regarding individual factors, work environment factors, and mental health status measured using the
12-item General Health Questionnaire (GHQ-12) was surveyed. The survey period was from June 10 to July 15,2021. We asked the respondents for a response regarding the situation during the fourth wave of COVID-19 infectious spread. For analysis, participants were divided into two groups according to a cut-off point of the GHQ-12
score, and the χ2 test was conducted. Afterward, stepwise logistic regression analysis was conducted. Results:
The data of 640 participants were analyzed (valid response rate: 48.5%). Of the 640 participants, 64.2% worked in
the infectious diseases section. Among the participants, 63.6% reported working overtime every day, and 38.3%
reported working every weekend. Regarding the mental health status, the mean GHQ-12 score was 6.3±3.4, and75.5% of the participants had a higher level of psychological distress. As shown in the result of the logistic regression analysis, the items “belonging to the infectious disease section” (OR = 1.73), “frequency of working overtime”(OR = 2.23), “frequency of working on the weekends” (OR = 2.11) and “workplace social support” (OR = 0.31) affected the PHNs’ mental health. Conclusions: This study revealed that the mental health status of PHNs was at a
critical level during the COVID-19 pandemic, and the needs for immediate mental health support for PHNs was
suggested.
Keywords
COVID-19, pandemic, public health nurses, mental health, related factors
JINR 2023, 2(1), e2022-0007

Introduction
Coronavirus disease 2019(COVID-19), which was first reported in Wuhan City, Hubei Province, China, in December
2019, soon spread across the world; The World Health Organization (WHO) declared COVID-19 a worldwide pandemic on March 11, 2020 (WHO, 2020). For approximately

two years since the emergence of the disease, efforts to develop a coronavirus vaccine have been ongoing as vaccination is a major means of containing the COVID-19 infection
rate. However, owing to the spread of various of COVID-19
variants, there still seems to be no prospects for the end of
COVID-19. In Japan, COVID-19 has spread steadily since
the first wave of the COVID-19 pandemic (between April

Correspondence: K. Tsuruda. Email: dofy102300@gmail.com
Received: February 28, 2022, Accepted: June 25, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 12JINR 2023, 2(1), e2022-0007

and May 2021). The total number of infected individuals
reached more than 2.6 million. Furthermore, more than
18,000 people have died as of January 31, 2021 (Ministry of
Health, Labour and Welfare, 2022).
Given this critical situation, many concerns regarding the
pandemic’s impact on the mental health of health professionals who have been working to prevent the spread of theinfection have been raised because they have been facing
continuous exhaustion and intense stress. In fact, a study on
the mental health of Japanese medical professionals during
the COVID-19 pandemic showed that more than 60% of theparticipants had mental health problems (Tahara, 2021). Several overseas surveys have also clarified that medical professionals are experiencing stress reactions such as anxiety, depressive symptoms, and mental distress during the COVID19 pandemic (Anliu, 2020; Si, 2020; Suryavanshi, 2020).
Under the Japanese public healthcare system, publichealth centers (PHCs) situated at the prefectures, ordinancedesignated cities, core cities, special wards and other designated cities are responsible for conducting COVID-19related work (e.g., active epidemiological investigation, hospitalization adjustments, and telephone counseling for residents). However, after the establishment of the Community
Health Act, the number of PHCs decreased from 847 to 469
between 1994 and 2020. Currently, this has caused a yearlydecrease in the number of staff members working in PHCs
(Ministry of Health, Labour and Welfare a; b). Given thissituation, PHC staff members have been experiencing exhaustion. Approximately half of PHC staff members in one
domestic PHC have been found to have mental health problems such as insomnia, mental distress, post-traumatic stressdisorder, depression, and anxiety during the COVID-19 pandemic (Usukura, 2021). However, the number of participants
number in this survey was 23, which is very small sample.
Currently, among PHC staff members, public healthnurses (PHNs) are playing a central role in COVID-19related work (Honda, 2021). PHNs conduct regular work as
well as COVID-19-related work (Kanzaki & Ijima, 2020),
so they are forced to work overtime or work on weekends into handle the large volumes of work in this pandemic-period(Sato, 2020). Furthermore, PHNs have been facing slander
from infected persons, their families, and residents, who areopposing their COVID-19-related work (Sato, 2020). These
facts demonstrate the harsh conditions faced by PHNs who
have been working to contain the COVID-19 pandemic. A
survey in the Philippines showed that, compared to nurses,
PHNs were more fearful regarding facing discrimination because of their involvement in COVID-19-related work. Thiswas because PHNs’ work includes dealing with individuals
regardless of whether such individuals are infected (Labrague, 2021). Considering these working conditions and thecharacteristics of PHNs’ work, it could impact the mental
health of PHNs during the COVID-19 pandemic in Japan is
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affected. PHNs perform important roles related to maintaining and promoting the health of the community health (Ministry of Health, Labour and Welfare, 2013). Thus, the functioning of PHNs is directly related to the health of the community.
Some previous studies have examined the mental and psychological statuses of PHNs in emergency situations. They
examined PHNs’ lack of confidence in controlling a severe
acute respiratory syndrome (SARS) outbreak in Taiwan(Chih, 2006) and the physical and mental health problemsof PHNs who were dispatched to provide disaster support
after the East Japan Great Earthquake (Yoshida, 2017). Few
studies have examined the mental health status of PHNs
during nonemergencies, Imai reported that PHNs involved inmental health care showed a higher prevalence of burnout
compared with other PHNs who were working on other assigned sections (Imai, 2006). Furthermore, half of all PHNs
who were working on other assigned sections experienced
burnout symptoms (Imai, 2006). However, other studies
showed that the rates of psychological distress tended to below (Yamada, 2013), and results regarding PHNs’ mental
health status varied. To date, many studies have shown that
individual and work environment factors can affect PHNs’
mental health.
Among individual-level factors, age (Lee, 2002; Saito,
2016; Yamada, 2013), years of experience as a PHN (Lee,2002; Saito, 2016), years of being employed at the current
local government (Saito, 2016), and years of experience as aclinical nurse (Lee, 2002) have shown that young PHNs
tend to have mental health problems. Moreover, it has beenfound that work environment factors, including frequency ofworking overtime and hours of working overtime (Saito,
2016; Yamada, 2013), taking breaks while at work (Saito,2016), and lower levels of continuous education (Lee,2002), are related to critical impacts on mental health. Furthermore, social support in the workplace has provided abuffer effect on mental health (Ozaki, 2014). In brief, theseresults showed that a heavy workload and the lack of opportunities to maintain motivation negatively affected mental
health and that mental health can be maintained if good relationships are maintained in the workplace.
Considering these circumstances, PHNs have supposedly
faced mental health problems under the COVID-19 pandemic conditions. If many PHNs have mental health problems, such psychological issues could interfere with theirregular work as well as their COVID-19-related work.
Therefore, it is necessary to help PHNs take measures tomaintain good mental health. For this purpose, we must perceive PHNs’ mental health status and reveal what factors
could affect it.
On the basis of the abovementioned considerations, thecurrent study investigated the mental health status of PHNs
in PHCs and analyzed any related influencing factors duringhttps://doi.org/10.53044/jinr.2022-0007

the COVID-19 pandemic.

Materials and Methods
Participants
The study participants included 1,320 full-time PHNs working in PHCs across Japan.
Stratified sampling was used to select the study participants, and 469 PHCs were divided into two groups based on
the presence or absence of certain emergency declarations.
These emergency declarations included “a declaration of astate of emergency,” “a state of semi-emergency related tocoronavirus measures,” and “a state of prefecture-specificemergency.” Subsequently, 165 PHCs were selected fromeach group using random sampling. We asked the supervising PHNs to select four PHNs (one PHN, 1-5 years of experience; two PHNs, 6-20 years of experience; and one PHN,
more than 21 years of experience) per PHC. This was conducted to reflect the previous study’s result of clarifying that“years of experience as a PHN” was related to the mental
health status, especially for PHNs who have been working
for 1-5 years (Saito, 2016) and the age composition of thestatistical population in the participation of this study.
Survey Methods
This study employed a quantitative and descriptive study
method. An anonymous self-administered structured questionnaire was distributed by mail. We mailed the questionnaires to supervising PHNs and asked them to distribute asurvey cooperation request document, questionnaire, and return envelope to the four PHNs. The participants returned
the questionnaire using the provided return envelope. The
survey was conducted from June 10 to July 15, 2021.
Survey Contents
The survey included individual factors, work environment
factors, mental health status, and free description regarding
difficulties during the COVID-19 pandemic. The respondents
were asked to respond to the situation during the fourthwave of the COVID-19 infectious spread from April to May
2021. Furthermore, a pretest was conducted for 14 PHNs tohelp in revising the questionnaire.
Individual Factors
Attributes of the Municipality to which the Participants Belonged
The items included the type of municipality to which theparticipants belonged; announcement of “a declaration of astate of emergency,” “a state of semi-emergency coronavirus
measures,” or “a state of prefecture-specific emergency,”;
and the state of occurring clusters in the PHCs’ district areas.
Individual Characteristics
The items were sex, age, assigned section, years of experi-

JINR 2023, 2(1), e2022-0007

ence as a PHN, job position, marital status, presence of family members who are living together, presence of someone
whom the participants could consult for advice regularly regardless of someone in the workplace, and occurrence oflife events from April to May 2021.
Work Environment Factors
Working Conditions
The items were frequency of working overtime, mean timeof working overtime per month from April to May 2021,
frequency of working on the weekends, engaging in telephone counseling during night shifts, existence of workers
who are on administrative leave, and taking breaks.
Degree and Impact of Involvement in COVID-19-relatedWork
The items were degree of involvement in COVID-19-related
work, impact of COVID-19 on regular work, and degree ofinteraction with nonregular staff members.
Social Support in the Workplace
The scale of social supports in the workplace (Komaki,1994) was used to measure workplace social support. This
scale has 14 items, including 8 items related to emotional
support and 6 items related to instrumental support. The responses to this scale are marked on a five-point Likert scale,including responses such as “I don’t think so,” “I don’t
think that it says either,” “Neutral,” “I think that it says
either,” and “I think so.” Social support is evaluated basedon the total score of all items (minimum = 14, maximum =70). A high total score indicates that the participants havesocial support in the workplace.
The current author developed the scale used in this study
by modifying the original scale (Komaki, 1993), but he did
not verify its reliability and construct validity after making
the modification. However, this scale has specific contents
regarding workplace social support and some previous studies on nurses have also used it (Yamamoto, 2020). Hence,the scale was used in this study. In the survey data, theCronbach’s α coefficient of the social support scale was
0.95.
Mental Health Status
To assess mental health status, the 12-item General Health
Questionnaire (GHQ-12), which was shortened GHQ (Goldberg, 1972) and was translated into Japanese by Nakagawa(1995), was used. This scale was scored by using the GHQ
method and evaluated based on the total scores of all items(minimum = 0, maximum = 12), with a cut-off point of 4
(Honda, 2001). A high total score indicated a higher level ofpsychological distress. The GHQ measure assesses nonspecific mental distress and has been verified to have high reliability and construct validity.
Many scales have been developed to measure mental
health status, but the GHQ-12 can measure mental healthstatus comprehensively and easily. Furthermore, several
studies have used the GHQ-12 to measure the mental health
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status of medical staff during the COVID-19 pandemic (Dai,2020; Nie, 2020). Thus, the GHQ-12 was also used in thisstudy.
Definition of Terms
Mental HealthIn this study, mental health was defined as a “situation that
did not cause strong mental and psychological symptoms”
following the measure method of the GHQ.
Social Support in the Workplace
In this study, social support in the workplace was defined as“empathy, acknowledgment, and cooperation in the workplace” based on the contents of the workplace social support
scale (Komaki, 1994).
Statistical Analysis
In this survey, quantitative data and quantitative data by freedescription were obtained. However, only quantitative data
were used in the analysis in this study to statistically examine the related factors for mental health, and all quantitative
data were used.
First, descriptive statistics were conducted on the individual factors, work environment factors, and GHQ-12 score.
Second, on basis of the mental health status, two groups
were created using the cut-off points: the “no higher level ofpsychological distress” group and the “higher level of psychological distress” group. Next, the χ2 test was used to examine the differences between these two groups and each
item of the individual factors, work environment factors, andGHQ-12 score.
To conduct the χ2 test, each item was divided as follows.
Regarding “announcement of a declaration of a state of
emergency,” as well as items such as “a declaration of astate of emergency,” “a state of semi-emergency coronavirus
measures,” and “a state of prefecture-specific emergency,”
the response was “announced,” and “no declaration” was“not announced.” Regarding the state of occurrence of theclusters in PHCs’ district areas, items such as “large clusters” and “clusters” were indicated with “clusters occurred,”and the presence of “no clusters” was indicated with “clusters did not occur.” Furthermore, items related to years ofexperience as a PHN were divided into three groups: “1-5years” was indicated with “new period”; “6-10 years,” “1115 years,” and “16-20 years” were indicated with “midcareer period”; and “more than 21 years” was indicated as“management period.” Regarding frequency of working
overtime, “everyday” and “about 2-3 times a week” were indicated as “high frequency of working overtime” and “about
once a week” and “none” were indicated as “not high frequency of working overtime.” Furthermore, the mean timeof working overtime per month was divided into two groups
with 45 h per month, which is the limit on working overtime, as prescribed by Labor Standards Act. Regarding the
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frequency of working on weekends, “every week” and“about 2-3 times a month” were indicated as “high frequency of working on weekends” and “about once a month”
and “none” were indicated as “not high frequency of working on weekends.” The items related to taking breaks weredivided into two groups: “no break” and “took time to havelunch” were indicated as “did not take break,” and “tooktime to have lunch and relax” and “took as usual” were indicated as “took break.” Furthermore, regarding the degreeof involvement in COVID-19-related work, the items of“100%,” “90%-80%,” and “70%-60%” were indicated with“strongly involved”; the items of “50%-40%,” “30%-20%,”and “10% or no involvement” were indicated with “did not
become strongly involved.” Regarding the degree of
COVID-19’s impact on regular work, the items of “disrupted
regular work” and “rather disrupted regular work” were indicated with “strongly influenced” and the items of “rather
un-disrupted regular work” and “un-disrupted regular work”
were indicated with “did not strongly influence.” The item
related to the degree of interaction with nonregular staff
members was divided into two groups: “interacted as a task
manager,” and “not a task manager but interacted frequently” were indicted as “strongly interacted,” and “not atask manager but interacted sometimes” and “did not interact” were indicated as “did not strongly interact.” The social
support score was divided based on “the group had social
supports in the workplace” and “the group did not have social supports in the workplace.”
Finally, logistic regression analysis using the stepwise
method was conducted. Items with significant differences
based on the χ2 test were used as independent variables,
namely, sex, and age after checking for multicollinearity
among items with significant differences, and the two mental health status groups were used as the dependent variables. The significance level was less than 5% with regard
to two-tailed tests, and IBM SPSS 28 was used for the
analysis.
Ethical Considerations
Documents regarding this survey’s purpose and the methodof data collection and publication were provided to the participants. Moreover, the participants were assured that participation in the survey was voluntary, that they would notincur any disadvantages even if they did not participate, andthat their answers would be regarded as consent.
Furthermore, this study was approved by the Medical District Department Ethical Review Board of Kyushu University (Approval number: 2021-82).

Results
Of the 1,320 participants, 733 responded to this survey (response rate: 55.5%), and the data of 640 participants werehttps://doi.org/10.53044/jinr.2022-0007

analyzed (valid response rate: 48.5%).

JINR 2023, 2(1), e2022-0007

Table 1. Participant characteristics.
n = 640

Individual Factors
The individual factors of the participants are presented inTable 1. The rate of PHNs who “worked in regions where adeclaration of a state of emergency was announced” was
70.3%, whereas the rate of “large-scale clusters or clusters”
that occurred in jurisdictional areas was 79.1%.
Among the participants, gender-wise, females formed
91.9% of the sample and 30.0% of the total participants
were in their 20s. Furthermore, 64.2% of the participants
were working in the infectious diseases section.
Work Environment Factors
The work environment factors of the participants are shownin Table 2. Among the participants, the rate of working
overtime “everyday” was found to be 63.6%, the rate ofworking on “every weekend” was 38.3%, and the rate ofworking overtime “about 2-3 times a week” was 48.1%.
Furthermore, the average amount of hours working overtime
per month was 52.9±45.0 h, and the rate of working overtime for more than 45 h a month, which is the limit on
working overtime, as prescribed by Labor Standards Act,was 51.7%. Regarding taking breaks at work, 13.1% of theparticipants took a break “as usual” and 53.4% of the participants took time “to have lunch and relax” (53.4%).
Moreover, 69.4% of the participants responded that theirregular work had been affected by their involvement in
COVID-19-related work. Incidentally, 95.9% of PHNs working in the infectious disease section worked overtime highfrequently, and 72.9% of PHNs in the other sections did.
The mean score for social support in the workplace was
53.9±10.4.
Mental Health Status of PHNs during the COVID-19 Pandemic
Figure 1 shows the state of the GHQ-12 score.
In this study, the mean score of GHQ-12 was 6.3±3.4(minimum score = 0, maximum score = 12). After the
GHQ-12 score was divided based on the cut-off points, 157
participants (24.5%) were placed in the “no higher level ofpsychological distress” group and 483 participants (75.5%)
were placed in the “higher level of psychological distress”
group.
Related Factors of PHNs’ Mental Health Status during the
COVID-19 Pandemic
Results of the Relationship between the GHQ-12 Score andFactors Based on the χ2 Test
The results of the relationship between the GHQ-12 scoreand factors based on the χ2 test are shown in Table 3, 4.
Among the individual factors, the items of “a declarationof a state of emergency was announced” and “assigned sec-

Items

n (%)

Attributes of the municipality to which the participants belong
Type of municipality to which the participants belong
Prefectures
517 (80.8)
Ordinance-designated cities
25 (3.9)Core cities
84 (13.1)
Special wards
9 (1.4)
Other designated cities
5 (0.8)
State of declaration of emergency
The state of declaration of state of emergency
213 (33.3)
The state of semi-emergency coronavirus measures109 (17.0)
The state of prefecture-specific state of emergency
128 (20.0)
None
190 (29.7)
State of occurring clusters in PHC’s district area.
Large clusters
68 (10.6)
Clusters
438 (68.4)
None
134 (20.9)
Individual characteristics
Sex
Female
Male
Age
20s
30s
40s
50s
60s
Assigned section
The section of infectious disease
The section other than the section of infectious disease588 (91.9)
52 (8.1)
192 (30.0)
165 (25.8)
114 (17.8)
166 (25.9)
3 (0.5)411 (64.2)
229 (35.8)

Years of experience as a public health nurse
1–5 years
6–10 years
11–15 years
16–20 years
More than 21 years

187 (29.2)
119 (18.6)
71 (11.1)
62 (9.7)201 (31.4)

Job position
Staff
Chief class
Subsection chief class
Assistant director classManager class271 (42.3)
133 (20.8)
103 (16.1)
84 (13.1)
85 (13.1)

Marital status
Unmarried
Married249 (38.9)
391 (61.1)

Presence of family living together
Yes
No
Existence of someone to whom participants were able
to go for advice regularly
Yes
No
Occurrence of life events from April to May 2021
YesNo

472 (73.8)
168 (26.2)

620 (96.9)
20 (3.1)
140 (21.9)
500 (78.1)

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Table 2. Work environment factors of the participants.
n = 640
Items
Working condition
Frequency of working overtime
Everyday
About 2–3 times a week
About once a week
None
Mean time of working overtime per month from April
to May, 2021
>45 h
≦45 h
>80 h
≦80 h

n (%)

407 (63.6)
154 (24.1)
57 (8.9)22 (3.4)52.9±45.0
299 (48.3)
320 (51.7)
441 (71.2)
178 (28.8)

Frequency of working on weekends
Every week
About 2–3 times a month
About once a monthNone

245 (38.3)
308 (48.1)
59 (9.2)
28 (4.4)

Engaging telephone counselling in night shiftYesNo

396 (61.9)
244 (38.1)

Existence of workers on administrative leaveYes
No

238 (37.2)
402 (62.8)

Taking break
Took as usual
Took time to have lunch and relax
Took time to have lunch
No break84 (13.1)
116 (18.1)
342 (53.4)
98 (15.3)

Degree and impact of involvement in COVID-19 related work
Degree of involvement in COVID-19 related work
100%
80%–90%60%–70%40%–50%20%–30%10% or no involvement

153 (23.9)
202 (31.6)
121 (18.9)
62 (9.7)
83 (13.0)
19 (3.0)

Impact of COVID-19 on regular
Disrupted regular work
Rather disrupted regular work
Rather un-disrupted regular work
Un-disrupted regular work

444 (69.4)
160 (25.0)
25 (3.9)
11 (1.7)

Degree of interaction with nonregular staff
Interacted as a task manager
Not a task manager but interacted frequently
Not a task manager but interacted sometimes
Did not interact
Mean of social support score97 (15.2)
138 (21.6)
192 (30.0)
213 (33.3)
53.9±10.4

6 of 12tion” were significantly different. Furthermore, the participants who “worked overtime” frequently had a long “meantime of working overtime per month,” “worked on the weekends” frequently, had a frequent “degree of involvement in
COVID-19-related work,” experienced a strong “impact onregular work” because of COVID-19, and had a frequent“degree of interaction with nonregular staff members.” Furthermore, the items of workplace social support significantly
differed.
Factors Related to the Mental Health Status of PHNs Basedon Logistic Regression Analysis Using the Stepwise Method
The results of the logistic regression analysis using the stepwise method of factors related to the mental health of PHNs
are shown in Table 5.
Among the items that showed significant differences
based on the χ2 test, sex, and age, the items “belonging to
the infectious disease section” (OR = 1.73), “frequency ofworking overtime” (OR = 2.23), “frequency of working on
weekend” (OR = 2.11), and “social support score” (OR =0.31) showed significant differences.

Discussion
Characteristic of the Study Participants
Regarding individual factors, 70.3% of the municipalities towhich the participants belonged declared a state of emergency, and the rate of “large-scale clusters or clusters” that
occurred in jurisdictional areas was 79.1%. This showed thatmany study participants worked in the regions that witnessed a severe outbreak of COVID-19. Regarding individual characteristics, the ratio of men to women was the sameas that of the statistical population (Ministry of Health, Labour and Welfare, 2019). Furthermore, in this study, the rateof participants who were in their 20s was higher than that of
the statistical population (Ministry of Health, Labour andWelfare, 2020); this affected the high rate of new period
PHNs and general staff members. Moreover, 64.2% of theparticipants belonged to the infectious disease section. The
participants in this survey were involved in COVID-19related work under conditions of severe infection spread,and the proportion of participants in the younger generation
was higher than that in the statistical population.
Regarding work environment factors, over 85% of theparticipants frequently worked overtime and on weekends.
Furthermore, in this study, the rate of working overtime formore than 45 h a month was 30% higher than the figure
provided by a survey of Japanese workers in 2019 (Recruit
Works Institute, 2019). The rate of working overtime formore than 80 h a month, which may have caused deathfrom overwork, was approximately 20% higher than the figure provided by a survey of local government workers in2015 (Ministry of Internal Affairs and Communications,2015). These results showed that the participants worked inhttps://doi.org/10.53044/jinr.2022-0007

JINR 2023, 2(1), e2022-0007(n) 70The mean GHQ-12 score: 6.3 ± 3.4

Cut-off point
60

Number of people

50

40

30

20

n = 483 (75.5%)

n = 157 (24.5%)

10

0

0

1

2

3

4

5

6
7
GHQ-12 score

8

9

10

11

12

(point)Figure 1. Distribution of the GHQ-12 score showed the mean GHQ-12 score and the number and rate of “higher
level of psychological distress” and “no higher level of psychological distress.”

oppressive working conditions during the COVID-19 pandemic. Regarding taking breaks at work, approximately 70%of the participants did not rest at work, and this result reflected the present situation where the PHNs managed totake breaks (Sato, 2020). Furthermore, over 90% of the participants responded that their regular work was affected bytheir involvement in COVID-19-related work. This showedthat their regular work had been accumulating because of
their involvement in COVID-19-related work; this rise led tosevere working conditions.
The mean score for workplace social support was 53.9±
10.4; this finding matched that of a previous study that examined nurses (Yamamoto, 2020). Many previous studies
have investigated workplace social support using various social support scales. These results showed that nurses’ social
support scores were higher than those of other professionals(Hu, 2018; Temam, 2019), thus indicating that nurses had
social support in the workplace. Under critical situations,such as the COVID-19 pandemic, there have often been
concerns regarding confusion in the workplace and difficultyof obtaining social support. However, the social support
score of the PHNs matched that of the nurses in the previously mentioned study, so PHNs were found to have received workplace social support during the COVID-19 pandemic. Lanzetta proved that people in groups with burdens(for example, a time limit or some difficulty in communication with other members) took cooperative attitudes to conduct problem solving in the relevant situations (Lanzetta,
1995). The participants had to solve problems in a groupthat received a heavy burden, and this may have affected thesocial support scores in this study.
Mental Health Status of PHNs during the COVID-19 Pandemic
Several studies have examined the GHQ-12 score of PHNs
during normal times. In this study, the GHQ-12 score had amean of 6.3±3.4, and the rate of “higher level of psychological distress” was 75.5%. These results showed that themean GHQ-12 score was higher than 3 points and the rateof “higher level of psychological distress” was over 30%
higher than that of PHNs during normal times (Saito, 2016;
Yoshida, 2017).
Moreover, it was revealed that the rate of “higher level ofpsychological distress” for medical professionals was 25.1%
to 51.1% during the COVID-19 pandemic (Del Piccolo,2021; Nie, 2020). Compared to these findings, the rate of“higher level of psychological distress” observed in thisstudy was higher.
Furthermore, several studies have examined the mental
health status of healthcare professionals in critical situations.
These studies showed that the rate of “higher level of psychological distress” was 32.7% during the East Japan Great
Earthquake (Suzuki, 2014) and 21.9% during the Nepal
Earthquake (Shrestha, 2015). Different mental health scales
were used to determine this finding. These results indicatethat preserving PHNs’ mental health status during the
COVID-19 pandemic is of critical significance.
The effort-reward imbalance model (Siegrist, 1996) is a
useful framework for interpreting the results of the study.
This model showed that an imbalance between the efforts
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Table 3. Results of the relationship between the GHQ-12 score and factors based on the χ2 test (individual factors).
Mental health status
Items

No higher level ofHigher level ofpsychological distress group psychological distress groupn = 157
n = 483

Attributes of the municipality to which the participants belong
Type of municipality to which the participants belong
Prefectures131 (83.4)
Ordinance-designated city
2 (1.3)
Core city
20 (12.7)
Special ward
2 (1.3)
Other designated cities
2 (1.3)
State of declaration of emergency during the 4th wave of the COVID-19 infectious spread
Announced
100 (63.7)
Not announce
57 (36.3)
State of occurring clusters in public health centers’ district area
Clusters occurred
121 (77.1)
Clusters did not occur
36 (22.9)
Individual characteristics
Sex
Female143 (91.1)
Male
14 (8.9)Age
20s
50 (31.8)30s
46 (29.3)
40s
28 (17.8)50s
31 (19.7)
60s
2 (1.3)
Assigned section
The section of infectious disease
79 (50.3)
The section other than the section of infectious disease78 (49.7)
Years of experience as a public health nurse
New period
138 (28.6)
Mid-career period
184 (38.1)
Management period
161 (33.3)
Job position
Staff
74 (47.1)
Chief class32 (20.4)
Subsection chief class23 (14.6)
Assistant director class18 (11.5)
Manager class10 (6.4)
Marital status
Unmarried
57 (36.3)
Married100 (63.7)
Presence of family living together
Yes
123 (78.3)
No
34 (21.7)
Existence of someone to whom participants were able to go for advice regularly
Yes
155 (98.7)
No
2 (1.3)Occurrence of life events from April to May 2021
Yes
31 (19.7)
No
126 (80.3)

8 of 12p value

386 (79.9)
23 (4.8)64 (13.3)
7 (1.4)3 (0.6).34350 (72.5)
133 (27.5)<.05385 (79.7)
98 (20.3).48445 (92.1)
38 (7.9).68

142 (29.4)
119 (24.6)
86 (17.8)
135 (28.0)
1 (0.2).13332 (68.7)
151 (31.3)<.01

49 (31.2)
68 (43.3)
40 (25.5).18

197 (40.8)
101 (20.9)
80 (16.6)66 (13.7)
39 (8.1).68

192 (39.8)
291 (60.2).44349 (72.3)
134 (27.7).13465 (96.3)
18 (3.7).12

109 (22.6)
374 (77.4).46https://doi.org/10.53044/jinr.2022-0007

JINR 2023, 2(1), e2022-0007

Table 4. Results of the relationship between the GHQ-12 score and factors based on the χ2 test (work environment
factors).
n (%)
Mental health status
Items

No higher level ofHigher level ofpsychological distress group psychological distress groupn = 157
n = 483

Working condition
Frequency of working overtime
High frequency of working overtime
116 (73.9)
Not high frequency of working overtime
41 (26.1)
Mean time of working overtime per month from April to May 2021
> 45 h84 (56.8)
64 (43.2)≦ 45 hFrequency of working on the weekends
High frequency of working on weekend
Not high frequency of working on weekend
Engaging telephone counselling in night shift
Yes
No
Existence of workers on administrative leave
Yes
No
Taking break
Took break
Did not take break

p value

445 (92.1)
38 (7.9)<.01215 (45.6)
256 (54.4)<.05

117 (74.5)
40 (25.5)436 (90.3)
47 (9.7)<.01

89 (56.7)
68 (43.3)

307 (63.6)
176 (36.4).12

55 (35.0)102 (65.0)

183 (37.9)300 (62.1).52

74 (47.1)
83 (52.9)

126 (26.1)
357 (73.9)<.01381 (78.9)
102 (21.1)<.01

462 (95.7)
21 (4.3)<.05

Degree and impact of involvement in COVID-19 related work
Degree of involvement in COVID-19 related work
Strongly involved
95 (60.5)
Not strongly involved
62 (39.5)
Impact of COVID-19 on regular work
Strongly influenced
142 (90.4)
Not strongly influenced
15 (9.6)
Degree of interaction with nonregular staff
Strongly interacted
Did not strongly interact

41 (26.1)
116 (73.9)

194 (40.2)
289 (59.8)<.01

Social support score
Group had social support in the workplace
Group did not have social support in the workplace

122 (77.7)
35 (22.3)

253 (52.4)
230 (47.6)<.01

expended toward working and the rewards obtained becauseof work could cause mental health problems. A previous
study on nurses’ burnout indicated that nurses who experienced imbalance between the efforts expended toward working and the rewards felt more emotional exhaustion compared with nurses who did not (Bakker, 2000). The survey’s
administration period coincided with the fourth wave of the
COVID-19 infection spread. The number of infected patients
increased, and PHCs were recruited to manage such patientsor conduct follow-ups with patients undertaking selfisolation. On the basis of the work conditions for thoseworking overtime or on the weekends, it was assumed that

PHNs would have to make efforts to deal with this work.
However, some patient deaths had been caused by their inadequate management of infected patients, and PHNs were
often allegedly slandered by mass media and the residents(Sato, 2020). This situation shows that PHNs did not receive
sufficient rewards for their efforts. During the COVID-19
pandemic, PHNs worked under stressful conditions including the tension of dealing with emergencies, and they often
experienced an imbalance between the efforts that they expended toward their work and the rewards that they received
for working. This situation may have affected their mental
health status.
9 of 12JINR 2023, 2(1), e2022-0007

https://doi.org/10.53044/jinr.2022-0007

Table 5. Factors related to the mental health status of PHNs basedon stepwise logistic regression analysis.
Items
Assigned section
Frequency of working
overtime
Frequency of working
on weekend
Social support
Hosmer-Lemeshow test

Regression
Coefficient

Odds Ratio(95% CI)p value

0.55
0.80

1.73 (1.14-2.63)
2.23 (1.24-4.02)

<.01
<.01

0.75

2.11 (1.21-3.69)

<.01

−1.17
0.31 (0.20-0.48)
χ2 = 3.579 (F=4) p = .466<.01

work affected PHNs’ mental health.
Furthermore, this study found that workplace social support was related to the mental health status of PHNs; thisfinding matched those of previous studies on PHNs in anonemergency situation (Ozaki, 2014). In addition, during
the COVID-19 pandemic, it was revealed that perceived social support affected the mental health status of healthcare
workers (Schug, 2021). Many international studies haveshown that workplace social support provides a buffer effectagainst occupational stress (Fenlason, 1994; Komatsu,
2010). This study thus demonstrated the importance of
maintaining good relationships in the workplace.
Suggestions for Mental Health Care of PHNs

Factors Related to Mental Health Status during the COVID19 Pandemic
Logistic regression analysis showed that the items belonging
to the infectious disease section, frequency of working overtime, working on weekends, and workplace social support
affected the PHNs’ mental health.
PHNs working in the infectious diseases section experience a large psychological load because of official responsibilities and pressures, and this could have affected theirmental health. In previous studies, healthcare workers working on the front line in Turkey had high risks of mental
health problems during the COVID-19 pandemic (Şahin,2020). The PHNs working in the infectious disease section
had to work on the front line during the COVID-19 pandemic, so it was affected their mental health. In addition,
the number of infected people increased in the fourth waveof the spread of COVID-19 infection, and many PHNs fromother sections were also involved in COVID-19-related work
during this period. The PHNs dispatched from other sections
became involved in COVID-19-related work temporarily,
and PHNs working in the section related to infectious diseases had to continuously engage themselves in COVID-19related work and were thus exposed to the official responsibilities imposed upon PHNs as well as other pressures on along-term basis (Honda, 2021). These situations increased
their psychological load and it affected their mental health.
The extracted frequency of working overtime as a related
factor was found to match that found in previous studies.
Dnder the COVID-19 pandemic situation, working over 48 h
per week was associated with a higher risk of depression for
health care workers in Latvia (Valaine, 2021) and working
over 8 h a day was one of the risk factors for anxiety forphysicians in Bangladesh (Khatun, 2021). Working on weekends was also extracted as a related factor in this study. Several studies on other occupations showed that working conditions included “working for more than 8 h a day” and“working for more than 5 days per week”; these were related to mental health (Proctor, 1996). This study’s results
thus affirmed that conditions involving excessive and hard10 of 12

This study found that the mental health status of PHNs during COVID-19 was critical; this indicated the necessity of
immediately conducting mental health care for PHNs.
Overload situation needs to be improved to maintain mental health. It may be necessary to have a temporary periodof time away from COVID-19 duties by strengthening theemployment of part-time staffs, especially for PHNs in theinfectious disease section. Furthermore, this study also
found that workplace social support affected the mental
health status of PHNs during the COVID-19 pandemic. Administrators are expected to ensure that peer support is available.
Limitations of this StudyIn this study, the response rate was 55.5%, and the valid response rate was 48.5%. Thus, it cannot be said that thisstudy’s result reflected the entirety of the concerns of PHNs.
Furthermore, this survey was conducted after the spread of
COVID-19. Therefore, lack of time and energy of the PHNs
may have affected the response rate of the survey.
This cross-sectional survey-based study was conductedduring the fourth wave of the COVID-19 pandemic. Subsequently, the public health situation has changed because of
the outbreak of the fifth and sixth waves of the COVID-19
infection and the initiation of vaccination efforts, as well as
the development of oral anti-COVID-19 drugs. These newdevelopments could have also affected the mental healthstatus of PHNs. Moreover, many participants were working
in PHCs at regions with severe infections or in harsh working conditions; this probably affected the results regarding
PHNs’ mental health status. Furthermore, as this was across-sectional survey-based study, the results of this study
did not establish a causal relationship between PHNs’ mental health status and related factors.
Regarding the workplace social support in this study, theveracity of the interpretation of the results was limited because the validity of the scale has not been examined andhas not been used for PHNs.
Despite these limitations, this study was the first to inves-https://doi.org/10.53044/jinr.2022-0007

tigate the mental health status of PHNs and its related factors during the COVID-19 pandemic. Therefore, this study
could form the basis for developing provisions for PHNs’
mental health care.
Conclusion
This study aimed to clarify the mental health status of PHNs
and its related factors during the COVID-19 pandemic. Consequently, the mental health status of PHNs was found to be
critically affected by items belonging to the infectious disease section, frequency of working overtime, working on
weekends, and the workplace social support; these were extracted as related factors.
Considering these related factors, the provision of mental
health care for PHNs should be undertaken urgently.
Author Contributions
Karen Tsuruda and Yoko Hatono contributed to the conception and design of this study, performed the statistical analysis, drafted the paper, revised it critically, and approved of
the final version to be published.
Declaration of Conflicting Interests
We have no conflict of interest to disclose.
Ethical Approval
This study was approved by the Medical District Department Ethical Review Board of Kyushu University [No.
2021-82].
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https://doi.org/10.53044/jinr.2021-0032
https://www.jinr.jsnr.or.jp/

Original Research

Factors interfering with behavioral change in patients with non-alcoholic
fatty liver disease: An ethnographic study
Takahiro Kawabata, RN, MSN1 , Michiko Moriyama, RN, MSN, Ph.D2 , Mayumi Niitani, RN, MSN, Ph.D3 , andBasilua Andre Muzembo, MD, PhD4
1

Japanese Red Cross Hiroshima College of Nursing, Hiroshima, Japan, 2Graduate School of Biomedical and
Health Sciences, Hiroshima University, Hiroshima, Japan, 3Graduate School of Nursing, Yasuda Women’s
University, Hiroshima, Japan, and 4Graduate School of Medicine, Dentistry and Pharmaceutical Sciences,
Okayama University, Okayama, Japan

Abstract
Objective: The reason behind the constant denial to accept any kind of behavioral changes among non-alcoholic
fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) patients even after counseling and why behaviors that lead to disease progression are maintained is unclear. This study aimed to describe the daily living
behaviors of NAFLD/NASH patients and elucidate the reasons behind their inability to change their routines,
which are problematic as they lead to disease progression. Methods: A qualitative study was conducted using an
ethnographic design. The data collection methods included participatory observation, field note-taking, and semistructured interviewing of eight NAFLD patients in their daily lives at their homes and workplaces. SpradleyJINRJJ15s Developmental Research Sequence method was employed to analyze the data. This paper conforms to thestandards for reporting qualitative research. Results: Four themes were generated: (1) health beliefs built in thefamily, (2) difficulty in systematizing health knowledge, (3) dependence on food, and (4) social disadvantages.
Conclusions: NAFLD patients had negative influences from the family environment from childhood, lacked integrated knowledge about the risk factors, and developed food addiction. Furthermore, social disadvantages, suchas a stressful environment, an environment where there was less chance to have significant others to support
their treatment, financial difficulties, and lower educational background, influenced all factors.
Keywords
ethnography, behavioral change, NAFLD, reduced inequality, qualitative research
JINR 2023, 2(1), e2021-0032

Introduction
Non-alcoholic fatty liver disease (NAFLD) or its severe
form, non-alcoholic steatohepatitis (NASH), is the hepatic
manifestations of metabolic syndrome that has become themost prevalent chronic liver disease worldwide (Younossi etal., 2016). The number of patients with NAFLD/NASH has
increased worldwide, primarily due to unhealthy food habits

and sedentary lifestyles. Japan is not an exception regarding
the NAFLD/NASH epidemic. In Japan, the prevalence ratesof NAFLD and NASH are estimated to be around 29.7%(Eguchi et al., 2012) and 3% (Estes et al., 2018), respectively. NAFLD/NASH has also been linked to obesity andinsulin resistance (Koda et al., 2007; El-Serag, Tran, &Everhart, 2004). Since 2008, specific health guidance has
been provided to persons predisposed to high risk of meta-

Correspondence: T. Kawabata. Email: tk11189@jrchcn.ac.jp
Received: January 11, 2022, Accepted: August 14, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 10JINR 2023, 2(1), e2021-0032

bolic syndrome. Despite the health guidance, the current
obesity ratio (approximately 33% for men and 22.3% forwomen) has not changed in women but significantly increased in men between 2013 and 2020 (Ministry of Health,
Labor and Welfare, 2020). Because obesity is the most important factor in the onset of NAFLD/NASH (Koda et al.,2007), the prevalence of NASH is expected to increase further in the future. In Japan, 9.1% of cirrhosis is related to
NASH (Enomoto et al., 2020), and the liver carcinogenesis
rate from NASH was reported to be 5.29/1000 person-years
compared with 0.44/1000 person-years in NAFLD (Younossi
et al., 2016).
The medical treatment for NAFLD/NASH mainly focuseson the management of the risk factors, such as diabetes,
dyslipidemia, hypertension, and lifestyle changes (The Japanese Society of Gastroenterology and Japanese Society ofLiver, 2020). Weight reduction due to diet and exercise therapy has been reported to improve the progression of
NAFLD/NASH (Musso et al., 2012). Several studies havedemonstrated that the effects of lifestyle improvement interventions could be as short as 6 to 12 months (Promrat et al.,2010; Wong et al., 2013). For example, an initial bodyweight reduction of 7%-10% was observed in a span of 1
year with the intervention of dietary, exercise, and behavioral therapies that lead to better liver condition and improvement in steatosis (Promrat et al., 2010).
It has been reported that promoting behavioral changes
among obese people is difficult (Kimura, 2012). This suggests that to achieve a successful lifestyle intervention inthese people, we need to focus on their individual personality and social circumstances.
People with severe obesity also suffer from eating disorders, depression, and anxiety (Canivet et al., 2020).
Recently, Sugiyama et al. (2018) reported that psychological stress could induce binge-eating and lead to increased
body mass index (BMI) in female NAFLD patients. However, it is unknown why NAFLD/NASH patients overeat tocope with psychological stress. No studies have elucidated
why behavioral changes do not occur and why behaviors
that lead to disease progression are maintained, even when
educated about lifestyle-related improvements. In addition,
as background information on “why patients continue tohave unhealthy lifestyles,” the patient’s previous growth environment, habits, and experiences cultivated in the environment affect the recognition and understanding of illness.
Therefore, this study aimed to describe the daily living behaviors of NAFLD/NASH patients, identify their recognition, and understand the underlying factors that disturb behavioral change from occurring and the processes that cause
disease progression. Greater awareness of these behaviors
among nurses would help them consider a holistic approachand be more proactive in managing NAFLD/NASH patients,
which will help prevent further progression of these condi2 of 10

https://doi.org/10.53044/jinr.2021-0032

tions.

Materials and Methods
Study Design and Setting
We employed the micro-ethnography approach (Roper, &Shapira, 1999) to gain a deeper insight into the knowledge
and perceptions of NAFLD/NASH from the perspective of
patients who are unable to pursue their medical treatment.
The micro-ethnography approach was selected as it focuseson the unique issues of small groups of people and the generated knowledge that could be applied to healthcare practices (Roper, & Shapira, 1999). The study was conducted
between November 2015 and December 2016 in Hiroshima,
Japan.
Participants and Recruitment
The participants were outpatients (male and female, aged!
20 years) diagnosed with NAFLD/NASH. They were referred to the outpatient clinic by their general practitioner.
To recruit a broad range of NAFLD/NASH patients, purposive sampling was employed. Among the sample participants, we aimed to achieve a large range in terms of age,gender, and BMI. Purposive sampling was used to selectparticipants so as to understand what contributed to thenonadherence to medical treatment. The numbers of the participants were not predetermined, and no specific criteria
were set for exclusion.
Procedure (Participant Observation and Interviews)
The interview and participant observation were conductedby the principal investigator (PI) (the first author, a master’s
program student who took a qualitative research methodology class and concurrently worked as a nurse at the gastroenterology and metabolism department) and the second
author (a nursing faculty specializing in chronic care nursing). After obtaining consent, the PI and co-researcher visited once or twice the participants’ home and/or designatedplaces where they spend most of their time, places for theirdinning and grocery shopping, and work places for data collection.
We observed numerous aspects of the participants’ behavior that might influence the onset and progression of
NAFLD/NASH, such as daily activities, dietary habits,
cooking methods, lifestyle habits, and stress-coping strategies. We also monitored the daily lives of the family members who lived with the participant, and they were also
asked some questions about their lifestyle habits.
During the participant observation, we set semistructured
interviews using an open-ended protocol. The interviews
were designed to elicit the participants’ opinions about theirhealth, awareness and understanding of the illness, how tocope with the illness, family relationships, the presence orhttps://doi.org/10.53044/jinr.2021-0032

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Table 1. Interview guide.
Educational background• Please tell me about your final educational background.
Occupation• Please tell me about your current occupation and working style.
• Please tell me about your past occupations.
Eating habit• Please tell me about your current and past eating habits.
(number of meals per day, meal time, presence or absence of snacks, meal content)• How much do you spend on meals?
• Do you go out to eat? Where are the menu selection criteria?
• Is there any reason to take the dietary habit?
• What and what criteria do you buy when shopping?
Family• Please tell me about your family structure.
• Please tell me about your family’s illness, eating habits, and body shape.
• Are there any critical situations in your relationship with your family?
How did you get over it?
Illness• Do you know about your own illness?
• Please tell us about your treatment so far. (Opportunity for consultation, hospitalization history, experience of worsening medical condition)• Do you know about the problems that illness causes to your body? (If you don’t know the problem, why don’t you?)• Do you understand the treatment and test values for your own illness?
• Have you ever received medical treatment guidance? Did you understand it? Has there been any change in yourself due to the medical treatment guidance?
• Did the illness affect your daily life and work?
• Do you know what kind of medicine you are taking?
• What is the reason why the medical treatment behavior can be continued/cannot be continued?
• What do you think of your body shape? Why do you think so?
• Are you using folk remedies?

absence of illness in their family, and their life history (Table 1). Furthermore, specific questions such as information
on family size and members, age, gender, occupation,
comorbidities, and educational background were gathered.
Probing and active listening were adopted during the interview to collect information (asked when a question arises
during behavioral observation). The set interviews lasted
from 30 to 50 min and were conducted in places where theparticipants always visited. Field notes were taken, and theinterviews were recorded using a digital recorder with theconsent of the participants.
Data Analysis
The analysis followed Spradley’s Developmental Research
Sequence (Spradley, 1980). We started data analysis as soon
as the first participant observation was performed. The recorded interviews were transcribed verbatim after repeatedly
listening to the contents. The accuracy of the transcripts was
assured by the two researchers who were involved in thehome visits. The field notes were also used to strengthendata interpretation. These notes and dataset transcripts weremanually assessed using a thematic approach. We conducted
a domain analysis to find semantic relationships through aclose reading of the field notes and verbatim interview transcripts and discovered cultural domains. A domain is a category of cultural meaning. Next, we conducted taxonomic
analysis to determine how the domains are organized. Then,
we conducted a componential analysis to identify the meanings and relationships among the terms that make up thecore domains. Subsequently, cultural themes related to
NAFLD/NASH behaviors were discovered while elucidating
the relationships among the domains. Final themes werebased on whether they addressed our research questions related to NAFLD/NASH behaviors or not. In addition, we
analyzed the similarities and differences between the domains and how they relate to medical treatment adherence.
Any discrepancy in the identification of the domains andthemes was resolved by discussion and consensus. The participants were indicated as “Participants A, B, C, D, E, F, G,
and H.”
Trustworthiness
We used the “strategies to guarantee the truth” of the qualitative study (Holloway, & Wheeler, 1996). Combining theobservation and interview data (triangulation), the participants were asked to listen and review their statements
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Table 2. Basic attributes of the participants.
Participant

Age(year)A

60

DM, HT, colorectal polyps,
hypopharyngeal cancer, cataracts,
hepatitis C

B

30

C

Educational background (highest)

Occupation

BMI(kg/m2)

University
Under graduate

Unemployed (onwelfare support)

23.7

UnknownDM

Dropout ofhigh school

Dispatch cleaning services

48.2

Grandfather: DM

60

DM, HT

High school

Factory worker

30.0

Father: DM
Brother: DM

D

70

DM, HT, dyslipidemia,
chronic renal failure

High school

Clerical work

32.4

Father: DM
Brother: Pancreatic cancer

E

80

DM, HT, dyslipidemia

High school

Unemployed

23.5

Mother: DM, cerebral infarction
Brother: DM, cerebral infarctionF

50

DM, HT, DM nephropathy,
DM retinopathy

Junior college

Public servant

36.9

Father: DM
Mother: DM, HTG

40

Chronic heart failure,atrial fibrillation, sleep apnea syndrome

High school

Factory worker

68.4

Father: DM, myocardial infarction
Mother: StrokeH

50

DM, dyslipidemia,
left-lower extremity arteriosclerosis
obliteransHigh school

Unemployed (onwelfare support)

38.4

Mother: DM
Grandmother: DM

Medical history

Family medical history

Abbreviation: BMI = body mass index; DM = diabetes mellitus; HT = hypertension(checking participants), and discussion with seven certified
nurses specializing in chronic care nursing (expert review)
were used as the basis for qualitative research evaluation.
Ethics Statement
The study protocol was approved by the Ethics Committee
for Epidemiological Research of Hiroshima University (E81). The aim of this study was explained to every participant, and written informed consent for participation was obtained from each of them. This study was conducted in accordance with the Declaration of Helsinki.

Results
Description of the Participants Involved in This Study
Data from eight participants were analyzed (two men andsix women; age range: 30-80 years). Seven participants(88%) had a history of diabetes, and four (50%) had hypertension (Table 2).
From the participant observations and semistructured interviews, we found four cultural themes: 1) health beliefs
built in the family, 2) difficulty in systematizing healthknowledge, 3) dependence on food, and 4) social disadvantage (Table 3).
The processes involved in generating these cultural
themes are described in the following sections. In addition,
illustrative quotes are included in the text.

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Theme I: Health Beliefs Built in the Family
The participants felt that lifestyle-related illnesses, such as
obesity, were hereditary and thus tended to ignore the importance of taking preventive actions. Participant E said, “I
have a family history of being overweight.” The participants
reported witnessing that some of their family members lived
comfortably despite “Having lifestyle-related diseases in thefamily.” Being raised with beliefs that lifestyle-related illnesses are hereditary and therefore inevitable made participants casual about the danger of sickness and obesity. The
participants were not worried about the obesity of theirspouses and children. “The body image built within the family” diminished the perception of criticism and made it difficult to recognize it as a problem.
Participant C’s father also had high blood pressure. “Myfather had high blood pressure, I heard it was around 180
mmHg. If my blood pressure was around 160 mmHg, I cango for work.” Participant D stated: “My family and I do notthink that blood pressure of 150 mmHg or higher is a problem. I heard that my father had upper side (systolic) bloodpressure of 200 mmHg but he did not care about it.” When
we asked Participant G if she had ever thought about taking
care of her health in an environment where her family members were obese or had lifestyle-related diseases, she responded that she was fine because she had no symptoms
compared with her family members (“Comparing themselvesto their families”).
It is important to note that several participants lacked

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Table 3. Theme and domain.
Theme

DomainHealth belief built in thefamilyHaving lifestyle-related diseases in the family
Body image built within the family
Comparing themselves to their families

Difficulty in systematizing
health knowledge

Difficulty in interpreting health information
Lack of awareness of the disease/its severity
Difficulties in correctly judging the received health information
Denied having health issues (denial behavior)
Visiting a doctor is a treatment
Taking medicine is a treatment

Dependence on food

Habitual behavior in family eating patterns
Routine eating behavior
Eating improves mental healthSocial disadvantages

Changes in the living environment
Educational background
Financial difficulties
Family relationship
Lack of support from others
Dependence on others

knowledge about the disease and its causes. Therefore, theirdecisions about their health were solely based on comparison between themselves and their family members.
Theme II: Difficulty in Systematizing Health Knowledge
All participants received medical care and guidance, butthey were unable to systematically understand the information. Because of “difficulty in interpreting health information,” they were not able to integrate clinical and biologicalparameters to the severity of their condition.
Participant A said: “Till now, I cannot interpret liver function tests data, I judge them using my weight, whether myweight is heavy or light.” When the researchers asked her
whether she understood the information about nutrition provided in the outpatient setting, Participant A replied, “Is sodium a salt? My interpretation is that foods with less energy
tend to have more sodium.” When asked about the medical
guidance received at the hospital, participant B said, “I don’t
remember. I didn’t know anything about HbA1c.” Participant B also stated: “You can treat diabetes by just reducing
your weight, right! So, diabetes is not scary to me.” Participant B made her own interpretation and thought that if she
just needed to lose weight, she could cure herself without
seeing a doctor. This leads to a lack of a sense of urgency
and self-suspension from seeing a doctor.
Participant C said: “It’s good that I don’t know the numbers.”
Participant C cited her lack of understanding of the test
values as the reason why she did not feel threatened and did
not change her behavior. It was difficult for them to integrate their knowledge and data with their physical condition.

Moreover, they interpreted the data in their own way andlacked awareness of the disease and its severity (“Lack ofawareness of the disease/its severity” and “Difficulties incorrectly judging received health information”). Furthermore, even though a physician pointed out their health problems, they simply “Denied having any health issues.”
Participant F said: “My lab test results showed some abnormalities, but my doctor did not point it out. So, this isok” (the fact is that the physician explained to him theanomaly). Participant D and G emphasized the reasons why
they did not take care of their health: “I’m young, so absolutely okay,” and “I have no symptoms, so it’s okay.”
Seven of the eight participants stated that they continued
to consult their physicians without interruption since the first
consultation; this is because they believed that “Visiting adoctor is a treatment” and “Taking medicine is also a treatment.” The following expressions also indicated their denialof health issues:
Participant C said: “I regularly drink beer even though I
have gout. The medication helped me to heal my gout without quitting alcohol. For blood pressure, I just go to the hospital and take medicine. Only anti-hypertensive drugs cancure blood pressure. If I take my medicine, I do not need tochange my lifestyle because of my liver problem.”Indeed, even when participants got health explanations
from physicians, the health education was not accepted as
knowledge.
On the other hand, some participants talked about changes
in their behavior, even though it was hard to understand.
Participant A said: “I started to buy healthy foods after being instructed by the nutritionist at the outpatient clinic.”
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Participant A was observed to actually purchase the instructed menu items when accompanied on shopping trips.
After receiving nutritional guidance at the hospital, Participant D bought a measuring scale and measured rice at
home. In the refrigerator at home, there was also rice thatwas measured and divided into small portions. With guidance, they were able to implement simple things such asmeasuring quantities. They were able to take action on simple things that were easy to implement in their real lives,
such as choosing foods and measuring quantities, when instructed. They recognized that it was good for their bodies.
Theme III: Dependence on Food
The participants reported that the family environment influenced their food habits, i.e., their dietary habits were similar
to those of their family. For example, Participant B said: “I
was in a family of four, but the amount of food was quite
excessive for the consumption of four persons during eachmeal.” In Participant E’s home, there was always juice that
she would get from relatives and sweets for snacking that
her husband also liked. Participant F said that his father
liked to eat excessive fat, and his sons grew up on the same
diet, which indicated the habitual eating behaviors developedin the family. The persons in charge of purchasing and preparing the food were also responsible for influencing thefood choices. There was a common bias to choose foods
that were high in sugar and calories. The eating habits observed in the participants were similar to those of their family members, and by sharing these eating habits from childhood, the eating habits of the family members were passed
on to the participants (“Habitual behavior in family eating
patterns”).
The participants also had a habit of eating the same foodrepeatedly from a fixed menu (“Routine eating behavior”).
In Participant A’s home, there was a large amount of retort
food of the same type. When the researchers accompanied
her on shopping trips, the stores we went to, the route we
took at the stores, and the products we bought were all thesame and fixed each time. When we accompanied Participant A to dine out, he often chose the same restaurant andmostly ordered hamburgers. He said he had never paid attention to calories or nutritional balance. Participant B said:“I can eat similar meal every day without thinking about thenutritional balance, if I find it delicious.” When the researchers accompanied them on their shopping trips, they bought
bread, juice, fried foods, and sweets. At the supermarket,
they bought cheap junk food and high-calorie foods. Participant F said: “I’m a picky eater. I would eat what I liked, but
if I don’t like something, I wouldn’t eat it.” She talked
about her dietary preferences. In the kitchen of Participant
G, there were sweet breads and crackers. Participant G said:“I like sweets, so I always have sweet breads and crackers
in my kitchen to eat.” Thus, the participants’ eating habits
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were biased toward carbohydrates and high-energy items,
and they repeatedly consumed such food articles. Participants who had economic hardships did not have many options; they had to buy cheaper food.
In addition, the participants reported that “Eating improves their mental health.” They found that binge-eating
helped them cope with stress.
Participant G said: “During stressful situations, eating
helps me feel comfortable. As a result, I used to eat right after getting frustrated.”
Participant B said: “I calm down when I have food infront of me. I just like to eat. I want to eat without stress.”
Participants had developed food and eating addictions
with unhealthy eating schedules.
Theme IV: Social Disadvantages
Participant D was in debt, divorced, and sold her house to
pay off the debt. After the divorce, Participant D got an office job but was not financially able to afford it. Participant
E was forced to lower her standard of living due to the impact of her husband’s failure in business. Participant G wasa single mother who managed to make a living by working
as a cleaner. Similarly, there was a possibility that occupational instability, low wages, and irregular work, such asnight shifts, had adversely affected their living environment
along with their medical treatment. Unstable occupations
forced them to change work places, and becoming unemployed and being on welfare support have changed theirlives (“Changes in living environment.”). Their “Educational
background” had an effect on their employment and became
the reason behind their poor economic conditions. Threeparticipants reported that “Financial difficulties” caused theirchildren to give up on going to school, and they were awareof the fact that their parents’ declining economic conditions
would also affect their lives.
The participants noted needs that were not being met intheir daily lives. They were unmarried, divorced, or bereaved and lacked support from others (“Family relationships”), i.e., no family or friends to help them understandpotential health risks. For instance, Participant A was single
and described her experience of not being in contact withfriends: “I had nowhere to go, and I spent most of my timealone in my studio. I do not get support from anybody.”
Two single mothers, Participants D and G, complained
about the lack of help and support from society:“I have a small child, I have to work, and I haven’t
thought about myself for almost 10 years.” (Single motherD)“If something happens, I have to cope with the challenges
without support from anybody. At home, my children arefighting all the time. My daughter became an adult and left
home, and I miss her every day.” (Single mother G)
They suffered from lack of cooperation with their fami-

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Dependence on foodSocial disadvantages

Health beliefs built in thefamilyDiseaseprogression

Difficulty in systematizing
health knowledge

Figure 1. Relatiohship of cultural themes to the processes leading to the progression of NAFLD/NASH.
: Cultural theme,: Progression of NAFLD/NASH,: Order of influence.

lies. The women speaking here considered that “the lack ofsupport from others” and the lack of family support tended
to affect them both mentally and financially.
In the following excerpt, a woman (Participant E) described losing motivation to change her lifestyle and eating
unhealthy food as she saw her husband eating junk food:“Even though I have a family, I get little support from myhusband. My husband always drinks his favorite juice andsweets beside me, and I succumb to the temptation to eat
the same unhealthy foods.”
On the other hand, it was observed that the participants’behaviors changed with the support from others. For Participant A, an encounter with a physician has stimulated behavioral change focusing on treatment, and Participant H wasable to continue losing weight with the cooperation of her
husband, family members, and others. She observed changes
that drove her to continue medical treatment. The participants’ behavior depended on others for positive changes orfor negative influences (“Dependence on others”). The existence of significant persons in the participants’ lives and thepresence or absence of their support had an effect on the
medical treatment and behavioral changes.
This kind of social disadvantage made it difficult to pay
attention to one’s health and promoted overeating habits as a
coping strategy.

Discussion
We demonstrated the perspectives and daily life behaviors of
NAFLD/NASH patients. In addition, we generated cultural
theme and domains linked with the development of unhealthy behaviors, which potentially contribute to diseaseprogression. We interpreted the relations among the themes
and discussed the process presented in Figure 1. This understanding is vital to identifying opportunities for new therapeutic measures that can be provided to NAFLD/NASH patients.

Factors That Inhibit Patients from Adhering to Therapeutic
Education to Modify Their Lifestyle
Negative Influences from the Family Environment and Lackof Integrated Knowledge about the Risk Factors of NAFDL/
NASH
We found that perceptions and food habits within the family
influenced the lifestyle of the family and that of NAFLD/
NASH patients. The participants were reluctant to improvetheir lifestyle because many of them had flawed interpretations of their illnesses and lacked adequate knowledge that
could help them connect their condition and risk factors. In
addition, due to lack of knowledge, they made judgments
about their health status based on comparisons with theirfamily members. For instance, the participants interpreted
that obesity was not regarded as a health problem. They
compared themselves with obese people in their family;
most participants believed that obesity is only hereditary.
This view of health was largely shared by participants andtheir families, which means that the family environment isparamount in influencing personal health outcomes. Thisfinding may have important implications for nurses to engage family for health education. This view is in line withprevious studies suggesting the necessity of involvement offamily members in medication adherence when caring forpatients with low health literacy (Lauffenburger, Khan, Brill,& Choudhry, 2019).
Food Addiction
Our study also highlighted that addiction to unhealthy foods
was common. This dependence on unhealthy foods was
based on eating habits shared within the family from childhood. Their eating habits consisted of choosing foods highin sugar and calories and ordering the same food repeatedly
from a fixed menu. One factor that makes it difficult tobreak out of this eating habit is food addiction formed fromsuch a habit. High-fat foods, such as junk food, are highly
addictive (Berthoud, Lenard, & Shin, 2011). Indeed, intake
of high-fat and high-calorie foods can result in obesity andleptin resistance. Leptin resistance is implicated in the gene7 of 10

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sis of disrupting mechanisms that control eating (Considine
et al., 1996), i.e., leptin resistance stimulates appetite, leading to excessive calorie consumption and obesity, whichleads to a vicious circle. Intake of high-fat and high-calorie
food stimulates the reward system in the brain, resulting in a
rewarding effect, such as euphoria (Berthoud et al., 2011).
Considering that food addiction is based on the eating habits
ingrained in the family from childhood, it is difficult to stopovereating even if one’s diet is restricted. As a result, it isvery difficult to break this vicious cycle. Therefore, prevention requires dietary education from early childhood andeducation not only for patients but also for their families.
Furthermore, it is important to note that NASH patients tend
to be depressed, which negatively affects their dietary habits(Elwing, Lustman, Wang, & Clouse, 2006), and that bingeeating disorder is common among NAFLD patients (Zhang
et al., 2017). The participants in this study also experienced
stressful environments due to social factors and ate large
quantities of food to cope with stress. This allowed them tomaintain a good mental state. This type of behavior createsa vicious cycle that promotes eating addictions, which, inturn, lead to the onset and exacerbation of the disease.
Disadvantageous Social Situation and Behavior Toward
Medical Treatment
Our findings also indicated the negative effects of “social
disadvantages” on factors that impede the treatment behaviorof NAFLD/NASH patients, i.e., family-established views on
health and food addiction.
In this study, the participants were facing financial difficulties, and the economic situation was affecting their dietand education. Regarding this effect, the 2018 National
Health and Nutrition Survey (Ministry of Health, Labor andWelfare, 2020) reported that low-income households eat
fewer staple foods, entrees, and side dishes than highincome ones, and their nutritional balance is low. In addition, the Cabinet Office (2018) reported that the college andother education rate for households on welfare support is
36% (72.9% for all households). Ochanomizu University(2018) reported that family economic status and children’s
academic performance are strongly correlated. Low-income
individuals have lower academic performance, which affects
their career path. A similar situation was observed in theparticipants in this study. Financial distress led to loss offood choices and opportunities for learning. Loss of dietary
choices affects good eating habits, and loss of access to education makes it difficult to understand and build health information, leading to disease awareness and the formation ofa view of health. Incomprehension of information fromhealth professionals leads to “overconfidence in medical
treatment” rather than controlling behavior by oneself, leading to a stop of thinking that “it is okay if I receive treatment/medication.” This recognition or psychological defense
mechanism, such as denial, makes it difficult for the patients
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to initiate their behavioral change.
Socioeconomic conditions affect health behavior and create health inequalities. It was also reported that the lower
the socioeconomic status, the lower the social support (Saito
et al., 2005). Furthermore, it was observed that our participants were also more socially isolated. For those who tend
to depend on others, the situation where it is difficult to obtain support from the surroundings is a factor that hinders
adherence to therapeutic education or medical treatment behaviors. Social situations, such as divorce and bereavement,
are stressful experiences that impair people’s mental wellbeing, making it difficult to pay attention to one’s healthand thus leading to overeating as a coping mechanism
against stress; indeed, this is how food addiction is formed.
In this way, social conditions affect health perceptions,eating behaviors, and medical treatment environment. These,in turn, affect the onset, progression, and medical treatment
behavior of NAFLD/NASH. The World Health Organization(Wilkinson, & Marmot, 2003) has shown that social determinants are involved in the health status of an individual.
Therefore, the social situation has a great influence on one’sview of health, which is the basis of rehabilitation behavior,and has also hindered it or one’s adherence to treatment.
To Achieve High Levels of Adherence to Medical Treatment
Eliminating Health Disparities
Our findings indicate that adverse social situation caused
health disparities and, as a consequence, impeded adherence
to treatment procedures or lifestyle changes in NAFLD/
NASH patients. To improve the outcomes, healthcare professionals need to understand the patients’ situation and give
advice that is easy to implement both economically andcompetently. Foods that are less harmful to one’s health canbe selected regardless of the economic situation. Measuresneed to be taken to allow people to stay healthy without being affected by the social situation and home environment.
Suggestions for Nursing Care and Patient Education
During the interview, one participant changed his behavior
due to a positive relationship with his physician (driven byhis sincere attitude toward the patient). Furthermore, someparticipants were able to adhere to healthier food choices as
they were taught in a step-by-step manner how to purchasegroceries. From these points, nurses need to build relationships of trust with patients and have a collaborative discussion and easy, step-by-step guidance on patients’ behavioral
changes.
Our findings also indicated that the participants did nothave sufficient social support, making it difficult to follow
and continue with medical advice. It is necessary to create
an environment in which family members and supporters are
involved in the patients’ treatment and provide support. Efforts to support continued behavioral changes through telenursing and/or home-visit nursing between consultations arehttps://doi.org/10.53044/jinr.2021-0032

also considered effective. This can help patients adhere totreatment.
Limitations of This Study
Qualitative methods have limitations in terms of generalizability. Because six of the eight participants were women, it
is unclear whether our results are generalizable to men with
NAFLD/NASH. In terms of BMI, this population is representative of the NAFLD/NASH patients. In this study, it wasdifficult to obtain consent from working men, because visiting participants at home and attending interviews caused
time constraints. Therefore, it is necessary to verify whether
similar results can be obtained by conducting a study on
men in the future. For future studies, it would be better toalso consider the illness duration and differences in the illness duration among participants, which might yield useful
information about adherence levels.
Conclusion
NAFLD/NASH patients had a belief about health that had
been constructed during the course of their upbringing,which was mainly governed by the perspective of their family members. It was also observed that dependence on foodformed based on shared eating habits within the family. This
health belief and dependence on food along with social factors, such as financial difficulties and educational background, had a significant influence on their views about
health that subsequently hindered their behavioral changes.
Thus, it is necessary to understand the social situation of
NAFLD/NASH patients so as to change their stance about
health and health behaviors. Measures and a support systemthat can assist NAFLD/NASH patients in a better way arehighly recommended. For future studies, it is necessary toverify whether similar results could be obtained by conducting a study on men and to also consider the illness durationand differences in the illness duration among participants.
Author Contributions
Study conception and design: T.K. and M.M, Data collection: T.K. and M.M, Data analysis and interpretation: T.K.,
M.N., M.M. and B.A.M, Drafting of the article: T.K., M.N.,
M.M. and B.A.M, Critical revision of the article: T.K., M.
M. and B.A.M. All authors have read and agreed with thefinal submitted version of the manuscript.
Declaration of Conflicting Interests
We have no conflict of interest to disclose.
Ethical Approval
The protocol of this study was approved by the Ethics Committee for Epidemiological Research of Hiroshima University (E-81).

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Informed Consent
Informed consent was obtained from all participants involved in this study.
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Brief Report

Effectiveness of a cervical cancer prevention program to improve healthliteracy among Japanese undergraduate females in their 20s: A quasiexperimental study
Shiho Kawata, PhD, RN, PHN1 , and Emiko Saito, PhD, RN, PHN2
1

Graduate School of Nursing, Kyoto College of Nursing, Japan, and 2Graduate School of Human Health Sciences,
Tokyo Metropolitan University, Japan

Abstract
To improve health literacy (HL) regarding cervical cancer prevention, a health program for females in their 20s waspreviously developed. The present study aimed to examine the effectiveness of that program. We conducted aquasi-experimental study (with control groups) on female undergraduate students in a private university in Japan.
In total, 15 and 60 students were categorized into the experimental and control groups, respectively. Intergrouppair-matching using the identified variables yielded a final assessment population of 28 students (n = 14 in eachgroup). The data analysis consisted of group comparisons of the participants between baseline and final assessment using the Wilcoxon signed-rank sum test and McNemar’s test. Experimental group comparisons revealed asignificant difference in median HL scale scores (baseline, 57.0; final assessment, 66.0; p = .002), median
women’s health knowledge test scores (baseline, 14.5; final assessment, 16.0; p = .029), and the percentage ofparticipants who felt confident explaining their own body to a medical practitioner (baseline, Y = 14.3, N = 0.0; final assessment, Y = 100.0, N = 0.0; p<.001); however, no significant difference was found for cervical cancer
screening behavior. No changes were seen in any of the variables between baseline and final assessment in thecontrol group. These results indicated that our program was effective for improving HL, confidence in explaining
one’s own body to a medical practitioner, and women’s health knowledge test scores, but not for changing cervicalcancer screening behaviors. Further research is needed to determine how to provide more appropriate health programs for females in their 20s.
Trial Registration: University Hospital Medical Information Network Clinical Trial Registry (Trial No.UMIN
000032444).
Keywords
cervical cancer prevention program, female undergraduate students, health literacy
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Introduction
In Japan, cervical cancer rate among women aged 20-30
years has been rising (Foundation for Promotion of Cancer
Research, Japan, 2021). However, cervical cancer is prevent-able, which means that women should undergo regular
screening. Since 2008, the Japanese government has been
conducting a cervical cancer screening for women with ages
20-years and over. However, despite the Japanese government’s efforts, the cervical cancer screening rate remains

Correspondence: S. Kawata. Email: s_kawata@kyotokango.ac.jp
Received: November 19, 2021, Accepted: July 6, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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Table 1. Contents of the cervical cancer prevention program aimed at improving the female Japanese undergraduate students’ healthliteracy.
SessionTopic

Follow-up(once a month for 3 months)• Slides delivered via presentation
software

2. Knowing mybody• Menstrual periods• Slides delivered via presentation
software• Basal body thermometer, graph, andvaginal discharge model

3. Preventing
cervical cancer• Cervical cancer screening• Communication about condom use with partners• Slides delivered via presentation
software

4. Gynecologicalexams and
consultations• Overview of a gynecological examination• How to choose female health information• Participants’ mobile phones• A worksheet simulating agynecological exam

Topics 2 to 4

• Education sent as e-mails; one topic was sent at atime

• Participants’ mobile phones

around 40%, which is low compared with the nearly 70%80% as observed in other Organization for Economic Cooperation and Development member countries (Foundation for
Promotion of Cancer Research, Japan, 2021). Since 2012,
the Japanese government has refrained from promoting Human papillomavirus (HPV) vaccination, however, have resumed in 2022 (Ministry of Health, Labor and Welfare,2021). Increasingly, stakeholders have been highlighting theimportance of cervical cancer screening for women.
HPV is highly transmissible and now considered the mostcommon sexually transmitted infection (STI) in most populations (Castellsagué, 2008). Regarding STIs, the World
Health Organization (WHO) recommends providing a cultural and age-appropriate programs to sexually healthy boys
and girls (World Health Organization, 2014). However, inmost Asian cultures, many parents are reluctant to educate
their children on sexual health topics because sexuality is asocietal taboo (Lee et al., 2013); Japan is no exception tothis rule. Additionally, few opportunities regarding sex education are provided to students after graduating from highschool. In disproportion to such few opportunities, a previous study found that approximately 50% of Japanese women
pursue university education (Gender Equality Bureau, Cabinet Office, Government of Japan, 2019). As part of theWHO’s cervical cancer control, secondary prevention with afocus on screening is recommended for people with ages
30-years and below. Female undergraduate students are at
the beginning of sexual maturity period, which makes it animportant time to focus on the prevention of cervical cancer.
Given this background, it seems important to provide theJapanese women who are in their early 20s, who may be enrolled in a university, with a standardized and ageappropriate sex education. Correlatively, a concept on healthliteracy (HL), which is defined as one’s capacity to obtain,
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Materials• Explain educational objectives• Morbidity of cervical cancer

1. Introduction

Group lecture(one time)

Contents

process, and understand both the basic health informationand services that allow one to take appropriate health decisions (Berkman et al., 2010), has been shown to play an important role in women’s general health care. A systematic
review of HL and cervical cancer screening found that HL
was linked to cervical cancer screening behavior (Kim &Han, 2016). Regarding the methods on HL enhancement,
another review suggested that HL can be improved by providing people with an adequate information, effective communication, and structured education program (Nutbeam etal., 2018); doing so may help improve the Japanesewomen’s HL and promote cervical cancer prevention amonghigh risk group. In spite of this, there is no current study
that demonstrates the effects of a program which aims to
improve HL to prevent cervical cancer among female Japanese university students. To address this gap in knowledge, ahealth education program was previously developed to improve the HL in female Japanese undergraduate students
who are in their 20s (Kawata & Saito, 2018). The present
study aimed to examine the effectiveness of an HL programfor cervical cancer prevention among female Japanese university students.

Cervical Cancer Prevention Program andMethods
The program contents are shown in Table 1. The program
lasts about 50 minutes and consists of a group lecture and ademonstration to provide knowledge on the following: (i)use of basal body temperature thermometer and vaginal discharge model to understand one’s own menstrual cycle; (ii)gynecological disease cases (e.g., general STIs, cervical cancer) to learn about the recent trends in, and the preventionof, gynecological diseases; and (iii) using one’s own smart-

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phone to access health resources and worksheets regarding
gynecological examinations and consultations. The teachingmaterials used in the program were created using PowerPoint 2013 (Microsoft, Redmond, WA, USA). We utilized
this method for the teaching materials based on a literature
review on HL and women’s health (Corrarino, 2013), whichsuggested that readability, layout, and design were key components in developing effective print materials for learning.
In the original study in which we developed the program, all
the participants that were reported to have a higher level ofsatisfaction and understanding of the materials commented
that the level of difficulty was appropriate for the curriculum. Moreover, after the program completion, they showed
improved HL and women’s knowledge on health. However,three of the 14 participants thought the program lasted too
long (Kawata & Saito, 2018). Therefore, the time was shortened. Additionally, after a group lecture, we sent e-mails
containing the contents of the group lectures via their smartphones once a month for 3 months to promote knowledge
retention. Therefore, we changed the present study evaluation period to 6 months because of the addition of the emails, and adjusted the events with the cooperating university. The present program was carried out by a researcher
and a public health nurse who had practical experience andreceived training in our previous study.

Study Design, Participants, and Setting
We conducted a quasi-experimental study with intervention
and control groups after recruiting participants from a private university in one region of Japan. We asked a private
university association in a convenient region of Japan toprovide us a corporate university that would be eligible forparticipation. The selected university has two campuses. To
avoid cross-contamination of information between groups, as
designated by the cooperating university, the study participants were recruited from both campuses. Posters requesting
the student participation were placed in both campuses. The
inclusion criteria for both groups were as follows: (i) currently a female Japanese undergraduate student, and (ii) ages
20-years or above. The sample size for the present study
was based on our previous study (Kawata & Saito, 2018):
the effect size (r = 0.88) was calculated based on a Zstatistic of 3.12 with a difference of 8 mean points pre-postintervention and 13 participants. It was designed with apower of 80%, a significance level of 5%, and an effect sizeof 0.8, and there were 14 or more participants. This study
was conducted from March to October 2015. The start ofthe program was scheduled to coincide with the participants’course registration and health checkups. This study was approved by the Research Safety and Ethics Committee of theTokyo Metropolitan University Arakawa Campus 2014 (approval No. 14104). We informed all participants, both in

JINR 2023, 2(1), e2021-0029

verbal and written form, about the purpose of this study, andassured them that their personal information would be protected. We also informed them that their participation in thisstudy was voluntary. All participants provided written consent prior to participation.

Instruments and Study Protocol
We conducted an anonymous self-administered questionnaire
survey and managed the data using concatenate numbers.
The study variables were the participants’ basic attributes,
HL variables, and women’s knowledge on health. The participants’ basic attributes consisted of age, gynecologicalhistory, final sex education history, and cervical cancer
screening history.
The HL variables comprised HL scale scores, confidence
in explaining one’s own body with a medical practitioner(Y/N), questions to test participants’ cervical cancer screening behaviors (Y/N), and (only for those with no cervicalcancer screening history) intention to undergo cervical cancer screening in the future (Y/N). The assessment of cervical cancer screening behavior indicated whether the participants had undergone screening within 6 months after thestart of the program (Y/N). To assess HL scale scores, weused a tool previously developed by one of the authors(Kawata et al., 2014). This tool is composed of 21 items,with each item scored on scale ranging from 1 (extremelylow) to 4 (excellent). Cronbach’s α of the original tool was
0.88.
To assess women’s health knowledge (20 items), we used
an original test previously developed with reference to thepreceding studies on women’s health (Dimmitt Champion etal., 2013; Sandfort & Pleasant, 2008). As our study had aquasi-experimental design, we performed pair-matching at
the final assessment to control the confounding factors―
namely HL scale scores at the baseline. The evaluation protocol is shown in Figure 1.

Statistical Analysis
The data were analyzed using SPSS (version 23.0 for Windows; SPSS, Inc., Chicago, IL, USA). Statistical significance was set at p<.05. The statistical analyses consisted of
calculating the basic statistics and conducting comparisonsof each group regarding the participants’ basic attributes and
HL variables, as well as women’s health knowledge and cervical cancer screening behavior at the final assessment using
the Wilcoxon signed-rank sum test, Fisher’s exact test, andMcNemar’s test. We selected the nonparametric test in consideration of the possibility that a normal distribution could
not be secured because of the small number of samples.

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Experimental group
Eligible students (n = 32)
Consented to participate(n = 15)

Control group
Eligible students (n = 72)
Consented to participate(n = 60)

Experimental group
participants(n = 14)

Control group
participants(n = 60)

Did not participate(n = 1)Baseline: assessments

Baseline assessments

Cervical cancer prevention
program(lecture and e-mail delivered
monthly)

3 months: follow-up

No response(n = 6)

Control group
Final participants(n = 54)

Experimental group
Final participants(n = 14)
Follow up

6 months: final assessments

Control group
Final participants(n = 14)

Experimental group
Final participants(n = 14)
Final assessments(pair-matching)

Figure 1. Evaluation protocol for both groups
Evaluation protocol for both groups, including the number of participants and assessment periods
for each group. Each group was assessed before (baseline) and at 3 months (follow-up) and 6
months (final assessment) after the start of the program. As our study design did not include randomized group allocation, we had to control the confounding factors and conduct intergrouppair-matching at the final assessment of HL scale scores at baseline.

Results
Participants’ Characteristics
In total, 14 of the 32 students (43.8%) eligible for the intervention group and 60 of the 72 (83.3%) students eligible forthe control group agreed to participate in the study. At
follow-up, 14 (100%) students participated in the intervention group, whereas only 54 (90.0%) participated in the control group.
In this study, pair-matching was conducted at the final assessment using data from the baseline survey. This proce4 of 7

dure yielded a final population of 28 participants (n = 14 ineach group), all of whom had their data analyzed. The results of group comparisons regarding the participants’ basic
attributes after pair-matching at the final assessment were
not significant (Table 2).
Comparisons of Each Group between Baseline and Final
Assessments
Comparisons of each group between baseline and final assessments are shown in Tables 3 and Table 4. In the experimental group, significant differences were found in medianhttps://doi.org/10.53044/jinr.2021-0029

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Table 2. Comparisons of participants’ basic attributes after pair-matching in each group.
Experimental group (n = 14)

Control group (n = 14)

n (%)

n (%)

20.7 (0.7)

20.8 (0.8)

.807a

Yes
No

4 (28.6)
10 (71.4)

1 (7.1)13 (92.2).163b

Junior high school
High school

5 (53.7)
9 (64.3)

4 (28.6)
10 (71.4).500b

Variables

CategoryAge (years)
Gynecological history

Final sex education history

p-value

Note. Results tested by at-test and bFisher’s exact test.
Data are expressed as mean (standard deviation), n (%)

Table 3. Comparisons of the health literacy (HL) scale and women’s health knowledge at baseline and final assessment
after pair-matching in each group.
Experimental group (n = 14)
Variable
HL scale
Women’s health knowledge

Baseline

Final assessment

57.0 (51.3–60.0)
14.5 (13.8–15.3)

66.0 (62.0-71.0)
16.0 (15.0–17.0)

Control group (n = 14)

p-value.002.029

Baseline

Final assessment

57.0 (51.3–60.0)
15.0 (13.5–16.0)

58.0 (51.3–61.5)
13.5 (12.5–15.3)

p-value.861.107

Note. Results tested by the Wilcoxon signed-rank sum test.
Data are expressed as median (interquartile range)
HL: Health literacy

Table 4. Comparisons of participants’ confidence in explaining and health behavior at baseline and final assessments afterpair-matching in each group.
Final assessment
Variable

Category

Confidence in explaining one’s
body to a medical practitioner
Health behavior
Cervical cancer screening
Intention to undergo cervicalcancer screening in the future

Baseline

Experimental group (n = 14)
Yes

No

Yes
No

2 (14.3)
12 (85.7)

0 (0.0)0 (0.0)

Yes
No
Yes
No

2 (14.3)
2 (14.3)
4 (28.6)
5 (35.7)

0 (0.0)10 (71.4)
0 (0.0)5 (35.7)

p-value
<.001

.500
.063

Control group (n = 14)
YesNo

3 (21.3)
1 (7.1)1 (7.1)9 (64.5)

1 (7.1)0 (0.0)2 (14.3)
5 (35.7)

0 (0.0)13 (92.9)
1 (7.1)6 (42.9)

p-value
>.999

>.999
.219

Note. Results were tested using McNemar’s test. Data are expressed as n (%).

HL scale scores (baseline, 57.0; final assessment, 66.0; p =.002), and women’s health knowledge (baseline, 14.5; final
assessment, 16.0; p = .029), and the percentage of participants who felt confident explaining their own body to a
medical practitioner (baseline, Y = 14.3, N = 0.0; final assessment, Y = 100.0, N = 0.0; p<.001). No significant differences were found in regard to cervical cancer screening behavior or future intention to modify health behavior.

Discussion
This study found that the investigated health education pro-gram was effective in improving women’s HL and knowledge on health. As similar in Korea, a previous study reported that a cervical cancer prevention program had positive effects on cervical cancer knowledge for female university students (Mo et al., 2013). Namely, both previous findings and present studies indicate that receiving sex education
at university age is important for expanding sexual knowledge among undergraduate students.
However, no association was found between HL and cervical cancer screening behavior. There are four possible reasons for this. First, the participants’ cervical cancer screening behavior was evaluated too early; the year-round Japa5 of 7

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nese cervical cancer screening schedule goes from April tothe end of March of the following year (2016), and thisvariable was evaluated in the middle of 2015. Therefore, amethodological review is warranted to appropriately assess
this variable. Second, Japanese women can receive a freecervical cancer screening only in the location where they are
registered as a resident. University students in Japan often
stay in accommodations near their universities withoutchanging their resident registration; therefore, it is inconvenient to visit a clinic which is far from home or school. Corroborating this notion, a previous report states that inaccessible clinics, inconvenient locations, and appointment times
were barriers in cervical cancer screening participation(Chorley et al., 2016). Third, with regards to the possibilityof improving the female Japanese undergraduate students’cancer screening behaviors, previous studies have discussed
the influence of a primary physician’s recommendations.
Additionally, a study conducted to examine the relationshipbetween HL and recommendation adherence to undergo
breast cancer screening among Japanese women found thatbreast and/or cervical cancer screening behavior is associated with both receiving a recommendation and having a
primary care from a physician (Goto et al., 2019). However,this is only considered to be partly true due to the lack of ageneral primary care physician system in Japan. In otherwords, these studies indicate that a healthcare worker’s recommendations and encouragements may promote awarenessto cancer risk, and it is necessary to periodically provide
women with an age-appropriate and up-to-date health education. Finally, the emotional barriers may contribute to poor
cervical cancer screening behavior. A previous study reported that statements related to “fear of pain” and “embarrassment” seemed to be more prominent among Asian
women than among other ethnic minorities (Marlow et al.,2015). The results of that study suggest that many women
think that undergoing cervical screening for the first time
will be painful and uncomfortable. Thus, it seems necessary
to foster an environment that promotes a perception of comfort toward the procedure wherein women can comfortably
undergo cervical cancer screening. Regarding such participation, in Japanese culture, knowledge about the health ofJapanese women may be empirically conveyed from mothers
and grandmothers; correlatively, in Korea, a study that provided a health education on cervical cancer prevention formothers was shown to be effective in improving their cervical cancer and Pap test knowledge, as well as their confidence in communication with their daughters (Kim et al.,2017). The heightened self-efficacy then led them to recommend cervical cancer screening to their daughters. A possible method to overcome these emotional barriers may be theprovision of education program contents that are culturally
relevant; for example, contents that promote the inclusionand participation of young women’s mothers in their cervi6 of 7

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cal cancer screening and sex education. However, to overcome the behaviors on cultural barriers related to cervicalcancer prevention, it is necessary to consider the contents
that allow students who have undergone cervical cancer
screening to be involved as a peer-support staff.
The present results suggest that HL might not have a direct effect on health behavior. Further research is needed todetermine how to provide a culturally- and age-appropriate
sex education to improve HL among female undergraduate
students in Japan. In Japan, a high percentage of students
pursue higher education. In light of this, universities andother institutions of higher learning are the best places toprovide health education to young women in their early 20s.
Additionally, The Japanese education system offers regular
health checkups. We recommend that female undergraduate
students take these opportunities in order to raise awarenessabout the risk of cervical cancer and the benefits of screening.
This study had several limitations. First, although we established the sample size for each group based on a preceding study, the sample size was small for a quasiexperimental design. Second, our results are based on datafrom students attending a single university in Japan; all participants had a history of sex education up to high school,
and it can be said that this is a general situation for Japanese women. However, the results may not be generalizable
to all undergraduate females in Japan. Therefore, we believea randomized controlled trial with a larger sample size isnecessary to confirm the causal effects between the variables
analyzed in the present study. This study is a reanalysis andrevision of doctoral dissertation data.
Author Contributions
SK and ES conceived of the study and study design; SK
collected the data; SK and ES analyzed and interpreted thedata, drafted, and critically revised the manuscript for important intellectual contents. All authors read and approval
the final manuscript.
Declaration of Conflicting Interests
The authors declare that they have no competing interests.
Ethical Approval
This study was approved by The Research Safety and Ethics
Committee of the Tokyo Metropolitan University Arakawa
Campus (approval no. 14104).
Funding
This study was supported by a JSPS KAKENHI Grant for
Young Scientists (B) (number 15K20801), Japan. The funding body had no role in the design of the study and collection, analysis, interpretation of data, and writing the manuscript.

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Informed Consent
We informed all participants, both in verbal and written
form, about the purpose of this study and assured them that
their personal information would be protected.
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Brief Report

Possibilities and challenges of dialogic approach training for childguidance center staff
Akiko Kadoma, PhD, RN, PHN1 , Mami Yamamoto, PhD, RN, PHN2 , Midori Asano, PhD, RN, PHN3 ,Koji Shiraki, Clin. Psy.4 , Rikuya Hosokawa, PhD, RN, PHN5 , Hirofumi Sato, PhD, MD6 ,Hitomi Nakahata, MN, RN, PHN7 , and Mari Kato, MN, RN, PHN7
1

Graduate School of Nursing, Nagoya City University, Nagoya, Japan, 2Faculty of Nursing, Hamamatsu University
School of Medicine, Hamamatsu, Japan, 3Integrated Health Sciences, Graduate School of Medicine, Nagoya
University, Nagoya, Japan, 4Nagoya Connect & Share, Nagoya, Japan, 5Graduate School of Medicine and Facultyof Medicine, Kyoto University, Kyoto, Japan, 6Graduate School of Medical Sciences, Nagoya City University,
Nagoya, Japan, and 7Doctoral Program of Nursing, Nagoya City University, Nagoya, Japan

Abstract
Parenting support and abuse prevention are pressing agendas in Japan. In the 1980s, open dialogue (OD) has
emerged as a treatment option for mental illnesses in Finland. We held six training sessions using the OD approach at a child guidance center from 2017 to 2019. Each session consisted of a lecture and role-plays, and participants’ reflections were gathered through a feedback sheet after each session. Moreover, we interviewed one
staff member after the training. Our OD training with the child protection staff is reported, and the possibilities andchallenges are discussed. The participants were 104 staff members of the child guidance center, and in total, 73
feedback sheets informed us regarding the achievements and concerns of our training session. The categories ofawareness, new experiences, and trust to therapists emerged as achievements, whereas categories of questions,difficulties, uncertainty, and the need for further learning emerged as concerns. From a 102-min interview with one
child guidance staff, we acquired his interest in dialogue, impressions, and feedback on our training. He informed
us of the difficulties in dialogue between the families and facilities with authority, necessity of early contact, possibilities of OD in child protection, and suggestions for OD training. Our training was part of an exposure program.
However, the participants deepened their understanding of the dialogic approach. As per our findings, we realizedthat OD and its training were suitable for the field of parenting support. The conditions of organizational training,such as costs, timing, location, and resource availability, should thus be improved.
Keywords
open dialogue, training, reflecting, child protection, parenting support
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BackgroundIn 2020, over 200,000 child abuse cases were reported in Japan (Ministry of Health, Labour and Welfare, 2021). Parenting support and abuse prevention remain pressing issues inJapan. In fact, child protection staff is often exhausted fromhandling abuse cases. In previous studies, we examined the
feelings of a mother whose child had been taken away by
the authorities due to suspected child abuse. She emphasizedthat she strongly wanted the child protection staff to hear of

Correspondence: A. Kadoma. Email: akado@med.nagoya-cu.ac.jp
Received: January 18, 2022, Accepted: August 14, 2022, Advance Publication: January 26, 2023, Published: February 17, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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her parenting challenges (Kadoma et al., 2020). Family carerequires a partnership between parents and dialogue.
In the 1980s, open dialogue (OD) emerged as a treatment
option for mental illnesses in Finland. We have been interested in this approach for several years. Some studies haveclarified its effectiveness for psychosis, particularly schizophrenia (Bergström et al., 2018; Freeman et al., 2019; Seikkula et al., 2003). However, the application of OD to clientsoutside the medical field is limited, and only a few cases
have been reported. In Spain, OD was used for family therapy with multiple families (Putman & Martindale, 2021, p.
212).
Family care requires partnerships with parents and dialogue. In OD studies, both clients’ and therapists’ perspectives and experiences are deemed essential. Tribe et al.
(2019) explored the experiences of networking meetings
service users and clinicians during the implementation of
OD for a UK-based mental health service. Holmesland et al.
(2010) described the challenges associated with the transformation and emergence of professional identity in transdisciplinary multiagency network meetings and the use of OD.
However, OD has a simple principle. Putman and Martindale reported that a very good outcome of OD was obtained
from high-quality training programs (Putman & Martindale,
2021, p. 107). Originating in Western Lapland, OD training
typically requires 3-4 years. In recent years, it has also been
conducted in Europe, including Scandinavian countries (Putman & Martindale, 2021, pp. 107-139). In Japan, the Open
Dialogue Network Japan is known to hold training sessions
for professionals by inviting trainers from Finland.
Although various studies have been conducted on the OD,
few have been conducted on training participants’ feedback
or reflections. It is essential to understand a trainee’s perspectives of the achievements and concerns regarding OD
training to investigate the possibilities and challenges of the
OD approach and training.
We tried OD training with child guidance center staff for
3 years. Although we have reported the outline and the contents of our training (Hosokawa et al., 2020), we had not
qualitatively analyzed the reflection of the participants including personal interview data.

Aim
In this study, we aimed to (1) report our OD training withchild protection staff and reflection of the participants/trainees and (2) discuss the possibilities and challenges of using
this approach or training.

Methods
Study Participants
The study participants were child protection staff workers
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who attended our training sessions. The number of participants in each session ranged from 9 to 31, and the total was
104. All staff of the child guidance center was deemed eligible to attend. They attended the training as much as theirwork schedule had allowed. Of these participants, one wasinterviewed after the training.
Data Collection
We held six training sessions at a Child Guidance Center ina city from 2017 to 2019. This city was urban and locatedin the Tokai area of Japan. Data was collected through 73
feedback sheets submitted by the training attendees and an
in-depth interview with one training attendee. The childguidance center distributed and gathered feedback sheets after every training. The attendees responded to the feedback
sheets anonymously. We received them from the child guidance center with the attendee’s permission.
After six training sessions, we collected data through aninterview with a child guidance staff member who had attended the training. The interviewee was a primary worker
who handled the case which we modeled in our role-play.
He was dedicated to family care and interested in dialogue,
so we thought that he was an appropriate person who could
talk about experiences related to our research aim. The firstauthor asked him to reflect on our activity/training, his daily
work to support the family, and his thoughts regarding the
dialogical approach for a family with challenges. This interview was held at the first author’s institute for 102 min in
March 2019.
Regarding Our Training
The training consisted of a lecture on OD and conversations(Table 1). They included the principles and key elements ofOD (Olson et al., 2014). The participants role-played imaging families for whom the staff members cared for. The staff
played the roles of the client, family, related people surrounding the clients, and facilitators. The role-play included
conversations using open-ended questions and responding to
the clients’ utterances. Each session lasted 120-180 min. Although OD training typically requires 3-4 years, our training
was adopted as a part of the professional development efforts at a child guidance center. Therefore, it was not intensive or long term. The researchers were trainees of various
backgrounds and specialties: three public health nurses, apediatric nurse, a psychiatrist, a psychological therapist, anda cultural anthropologist. Some members were theoreticaland methodological leaders of dialogic approaches in Japan.
Data Analysis
Data analysis in this current study consisted of three steps:(a) organizing feedback comments, (b) constructing categories based on similarities and differences, and (c) findingachievements and concerns related to the training program.

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Table 1. Contents of the training sessions.
SessionMonth/Year

Contents

Number ofParticipants

Number of
Responses

1
2
3
4
5
6

Feb-17
Jul-17Jan-18Aug-18Oct-18Mar-19Welcome, Lecture, Reflection exercise
Role-play to become clients and families
Facilitation exercise
Reflection exercise
Practice of open dialogue
Role-play of open dialogue

16
20
31
9
18
10

6
12
27
8
13
7

Table 2. Reflections of the participants in our training.
Achievements

Concerns<Awareness>
Participants realized the unique characteristics of the open dialogue
approach that emphasizes respect and dialogue.
<New experience>
They had new experiences of imagining the clients’ situations.
<Trust to therapists>
They developed trust in the therapists.

<Questions>
Participants raised practical questions.
<Difficulties>
They expressed challenges in the technical aspects of the open dialogue approach.
<Uncertainty>
Some felt uncertain regarding the characteristics of OD being tolerantof ambiguity.
<Need for further learning>
They expressed interest in learning more about OD.

In addition, we analyzed the interview data for the essenceof the informants’ narratives. We highlighted the importanceof his experiences and thoughts regarding our study aim
through the transcript. The informant who participated in the
personal interview checked the validity of our analysis.
Ethical Consideration
Participation in the training sessions was voluntarily, and theprivacy of the participants was ensured. Informed consent
was obtained from all participants involved in this study.
This study was approved by the Institutional Research Ethics Committee of the first author’s university (ID-16019-4).

Results
Participants’ Reflections on Our Open Dialogue Training
The 104 participants (in each session ranged from 9 to 31)
included psychotherapists, child welfare specialists, social
workers, and other professionals at the child guidance center. The number of participants depended on the availabilityof the staff. Sometimes, they were absent from the sessions
due to the unpredictable nature of their jobs. In total, 73
feedback sheets informed us regarding the achievements andconcerns of our training sessions. Table 2 shows the categories and subcategories of the comments from the participants.

Achievements
As an achievement, the categories of awareness, new experience, and trust to therapist emerged.
Awareness
This category meant that the participants realized the uniquecharacteristics of the OD approach that emphasized respectand dialogue. The participants said, “I gained multiple perspectives,” “I can apply this great skill to day-to-day counseling,” and “I learned that there is no immediate solution.”
New Experience
They had new experiences imagining the clients’ situations,such as a parent struggling. They noted that fresh perspectives would help them to offer better counseling. They said,“I found reflection helped me have an internal dialogue,
which I had never had before.”
Trust to Therapist
The participants developed trust in the therapists. They said
that “I enjoyed calm and direct conversations through therapists/facilitators” and “Therapists collaborate in responding
to client’s concerns.”
Concerns
Conversely, the participants also raised concerns; we thereafter categorized them into questions, difficulties, uncertainty,
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and need for further learning.

ing each other’s feelings.

Questions

Necessity of Early Contact

The participants raised practical questions, such as “I don’tknow if I can apply OD to my cases” and “facilitator’s skills
vary greatly.”

The social worker wished he could have provided continuous support rather than short-term advice. He told us “ourguidance on how to discipline children is only temporary,
and therefore, we cannot follow our advice. I am afraid thatthe child-parent relationships at home would be as bad as
before.” In addition, he wanted to contact the family earlier.
He said, “If we could engage with them earlier, the family
might have become happier.” Through our training, he wasable to realize that early conversations with parents regarding the problems could prevent abuse.

Difficulties
They expressed challenges in the technical aspects of the
OD approach. Their comments included, “effects of reflection are hard to understand” and “it is difficult to discuss theclient’s issues in front of her.”
Uncertainty
The participants understood some features of OD and felt
anxiety simultaneously. Some felt uncertain as regards thecharacteristic of OD being tolerant of ambiguity. They said,“I am not certain about conversation without goals,” and “I
am not sure about discussing without purposes and directions.”
Need for Further Learning
The participants expressed interest in further learning. Theircomments were as follows: “I want to observe the actual
practice of OD” and “I want to learn more about the theoretical background of OD.”A Child Protection Staff’s Feedback Gained from a PersonalInterview
The informant was a child protection staff member in his
30s and had a social welfare license. He previously worked
at a hospital as a medical social worker. After that, heworked for several years at a child guidance center. He was
the primary caseworker, who we role-played during thetraining. The first author conducted a 102-min interview
with the informant. Questions were based on his interest in
dialogue, impressions, and feedback on the training.
He mentioned the “difficulties of dialogue between thefamilies and facilities with authority,” “necessity of early
contact,” “possibilities of OD in child protection,” and “suggestion for OD.”
Difficulties of Dialogue between the Families and Facilities
with Authority
He said that “we have the authority to prohibit undesired behavior from parents and children.” Therefore, “the relationship between the worker and client is hierarchical.” Throughthe training, he realized that he had authoritatively communicated with his colleagues. He raised examples of these behaviors, such as not being willing to wait and talk, talking
about the clients without them, focusing on the risk rather
than parent-child strength, and overemphasizing organizational solutions, rather than parents and children understand4 of 6

Possibilities of Open Dialogue in Child Protection
The informant expressed his impressions regarding OD as
follows: “I felt that OD gave me diverse perspectives. I
found it interesting to see that two or more facilitators listen
to parents’ concerns. But we should be doing it already. A
facilitator’s role is important.” He understood the features ofthe family that were being challenged, “Parents are willingto open themselves to concerned people” and “When parentchild relationships are difficult, the family cannot discuss
their problems by themselves.” Therefore, he thought that“OD was suitable for less serious service facilities rather
than child protection offices.” “Responding to mothers’ SOS
by using OD may help avoid temporary protection and keep
their daily life going.” These narratives suggested the possibility of OD.
Suggestions for Open Dialogue Training/Practice
He mentioned ideas for understanding OD and promoting
training. He said, “It was important for supporters to get abetter image of OD and role-play the situation.” Therefore,
he proposed that an “image movie” would help us understand how we start an OD session. In addition, he said that“people from outside, such as researchers, rather than childprotection staff, should take the role of facilitators.” He concluded by saying, “We should reach out to families and havedialogue in a daily living context.”

Discussion
Studies on dialogic approach in child protection remain to
be limited; thus, we tried to practice and conduct research inthis field. As mentioned above, our training was part of an
exposure program for the child protection center staff, and it
was not intensive or engaging. However, we received somesuggestions on the possibilities and challenges of our OD
training.
First, as possibilities, the participants deepened their understanding of the dialogic approach. They realized theunique characteristics of OD, such as respecting multiple

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perspectives. Participants experienced clients’ situations
through role-plays and reflection, which resulted in internal
dialogue. We think that this promotes support workers’ continued interest in collaborating with clients. In our research,
participants developed trust to therapists/facilitators throughconversations in OD. Putman and Martindale (2021, p. 111)
also suggested observation/reflection on the importance oftrust within teams. Stockmann et al. (2019) reported trainees’ perspectives on training and peer-supported OD in the
UK. They found that the trainees were able to develop positive changes in their personal attitudes toward their clinicalwork (Stockmann et al., 2019). The trainees in our study
also reported awareness of their clients’ situation. We received suggestions from the interviewees that early conversations using OD could open the clients’ minds and, in turn,
prevent abuse. Therefore, we suggest that OD might be suitable for support centers that are popular among parents. In
Putman and Martindale (2021), it is said that the OD training process could be called unlearning and healing (p. 123).
In addition, Putman thought it was more accurate to speakof “releasing” rather than “unlearning” (Putman & Martindale, 2021, p. 108). Putman emphasized that OD training
helped participants in becoming more flexible and creativein their work (Putman & Martindale, 2021 p. 111). Our
training participants cultivated their self-awareness and developed their unique perspectives.
Second, as challenges, the participants raised issues of the
difficulty and uncertainty in OD. “Uncertainty” was a key
element of OD, and the participants learned this vital featureof OD in our limited training. They wondered whether they
could apply OD to their cases. They felt anxiety regarding
the tolerance of uncertainty, dialogue without a goal, and themeaning of reflection. In Stockmann et al.’s study, promoting dialogue, not change, was something that participants
struggled with. Additionally, tolerance of uncertainty was
also found to be difficult and in conflict with their work
(Stockmann et al., 2019). These findings were consistent
with our findings on trainees’ anxiety. OD is not a method,
but an attitude (Olson et al., 2014). Therefore, exercises toimprove listening skills and promote reflection are needed.
We gained suggestions through personal interviews andfound that communication between the parents and childprotection staff tended to be vertical. Thus, the staff members should consider a horizontal and understanding communication approach with parents. This approach was supported by the “not-knowing” approach (Anderson & Goolishian, 1992) that “the client was the expert” in their experiences. The need for early contact with the family can be addressed by the concept of “early dialogue.” It is another dialogic approach developed in Finland (Arnkil & Erickson,2009). Its dialogic approach suggests early conversation, notintervention among the family and related people.
This research has limitation, that is, only one facility par-JINR 2023, 2(1), e2021-0030

ticipated in the training, and only one staff member participated in the personal interview.
Our training is one of the trial cases of a dialogic approach that addresses the issue of community-based childabuse. The OD approach may be suitable for parenting support and child protection. We believe this approach supports
both parents with various challenges and child protection
staff. The conditions of organizational training, such as
costs, timing, location, and resource availability, should be
improved.
Acknowledgments
We would like to express our deep gratitude to the participants in our study. We would like to thank Editage (www.ed
itage.com) and Dr. Kaoru Kinoshita for English language
editing. This study was supported by JSPS KAKENHI Grant
Number 16K12304.
Author Contributions
Akiko Kadoma designed and conducted the study and prepared the manuscript. Midori Asano, Mami Yamamoto, Koji
Shiraki, Rikuya Hosokawa, and Hirofumi Sato contributed
to the concept and design of the study, data collection/analysis, and detailed interpretation. Hitomi Nakahata and Mari
Kato analyzed the data, interpreted the findings, and critically reviewed the manuscript. All authors critically reviewed the manuscript and confirmed the final manuscript.
Declaration of Conflicting Interests
The authors declare that there are no conflicts of interest.
Ethical Approval
This study was approved by the Institutional Research Ethics Committee of Nagoya City University Graduate Schoolof Nursing (ID: 16019-4).
Funding
This work was supported by JSPS KAKENHI Grant Number 16K12304.
Informed Consent
Informed consent was obtained from all participants involved in this study.
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Erratum

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JINR 2023, 2 (1), e2022-err001【統一事項】●図表とタイトルのアキ 2.5 ｍｍ ●イタリックの書体 Times Italic ●ギリシア文字 Symbol

Naoki Kuramoto, MSN, RN

Kuramoto, N., Watanabe, Y. (2022). Effectiveness of usingnear-infrared vein visualizers by nurses in promoting successful peripheral venous catheterization in patients receiving chemotherapy. Journal of International Nursing Research, 1 (1),e2021-0014. https://doi.org/10.53044/jinr.2021-0014
In the above-mentioned article, Table 3 unfortunately contained errors. The asterisks given for p value appeared incorrectly. The correct table should be shown as follows. The
authors regret the errors.

Table 3. Vein characteristics in the NIR vein visualizer group.
Veincharacteristic

NIR vein visualizer group
Success (n = 20)
Failure (n = 14)

p valueMean

SD Median

Mean

SD Median

Thickness
Elasticity
Tortuous veins
Rolling veins
Visibility

7.65
7.45
8.05
7.35
7.45

3.15
2.56
2.26
2.64
3.02

9.00
8.00
9.00
8.00
9.00

9.43
9.07
9.21
8.29
9.14

1.02
1.21
1.31
2.05
1.99

10.00
10.00
10.00
8.50
10.00

.05
.06
.07
.30
.02

Palpability

6.95

3.07

7.00

9.21

1.31

10.00

.01

*

*
Note. Results showed by Mann–Whitney U tests*p < .05; a score of 10 is more difficult than a score of 1
Abbreviations: NIR, near-infrared; SD, standard deviation

Correspondence: N. Kuramoto. Email: naoki-k@u-shizuoka-ken.ac.jp
Copyright Ⓒ 2022 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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List of Reviewers
The Editorial Committee members express their gratitude to the following individuals, who served as reviewers of manuscripts
for the Journal of International Nursing Research between April 2022 and March 2023.

Shizuko Angerhofer

Valentina Lucia La Rosa

Deborah Biggerstaff

Ziqiang Li

Jacqueline Bloomfield

Esther Wing Sze Lo

Vico Chiang

Maura Lusignani

Wai Leng Chow

Yuko Matsuda

Leona Cilar Budler

Darryl Maybery

Noriyo Colley

Jason Mills

Helena Dahlberg

Hanako Misao

Janet Finlayson

Yuki Miyamoto

Kimie FujitaPeter Nyda

Daisuke Furushima

Yuriko Ohkawa

Michel Galinier

Junko Okada

Yuka Hayama

Miho Okura

Yuta Hayashi

Mayumi Okuwa

Toru Hifumi

Mayumi Okuyama

Seiko Hirokawa

Dayananda B. Omkarappa

Filiz Hisar

Alvisa Palese

Kieko Iida

Rebecca Poon

Sumie Ikezaki

Kristina Rios

Mina Ishimaru

Emiko Saito

Mikiko Ito

Sayyed Ali Samadi

Yuko Itoi

Mayumi Sato

Conrad Kabali

Taiga Shibayama

Noriko Katayama

Takafumi Soejima

Hiromi Kawasaki

Kyoko Tanonaka

Kana Kazawa

Masae Tsutsumi

Alyson Keen

Tomoko Wakamura

Sachiko Kita

Kieko Yasuda

Kyoko Kobayashi

Naoki Yoshinaga

Rick Kwan