443

ORIGINAL
Factors associated with anxiety and depression among
caregivers of patients receiving medical home visits
Yoshihiro Okura MD1, Chisato Takeuchi MS2, Harutaka Yamaguchi MD, PhD2, and Kenji Tani MD, PhD1
1
Department of General Medicine and Primary Care, Tokushima University Hospital, Tokushima, Japan, 2Department of General Medicine,
University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan

Abstract : In recent years, Japan has promoted home visits to support older adults, with caregivers playing animportant role. However, caregivers generally experience a high frequency of anxiety and depression, and thefactors associated with these conditions among home visit caregivers remain unknown. To identify the associated factors, we conducted a questionnaire-based cross-sectional study of home visit caregivers in Tokushima Prefecture, Japan. The survey included caregivers’ Hospital Anxiety and Depression Scale ; sociodemographic itemsof patients and caregivers ; and caregivers’ perceptions of the home care environment, patients, and themselves.
The questionnaires were sent to 379 caregivers ; 203 responded (53.6% response rate), of which 173 were valid(85.2% valid response rate). The prevalence of anxiety and depression was 43.9% and 69.4%, respectively. Multiple
logistic regression analysis of factors associated with anxiety and depression showed that stable family finances (OR : 0.69, 95% CI : 0.48-1.00, p = 0.049) and stable caregiver health (OR : 0.45, 95% CI : 0.30-0.68, p < 0.001) wereassociated with anxiety. Further, stable family finances (OR : 0.60, 95% CI : 0.38-0.93, p = 0.022), stable caregiver
health (OR : 0.49, 95% CI : 0.30-0.81, p = 0.005), and stable patient condition (OR : 0.51, 95% CI : 0.29-0.92, p = 0.025)
were associated with depression. These findings demonstrate that caregiver wellbeing is essential in home caresettings. J. Med. Invest. 70 : 443-449, August, 2023
Keywords : anxiety, caregivers, depression, house calls

INTRODUCTION
In recent years, owing to Japan’s aging population, there has
been a rise in the number of older adults and couples who live
alone (1) ; moreover, an increasing number of family caregivers
are either residing with or living separately from older adults.
Hence, the need for a system to support older adults is growing. Since 2000, the Japanese government has strongly reinforced the coverage of home medical and long-term care services
through the insurance system. Japan’s long-term care insurance
system covers a wide range of services, such as those provided byhome helpers (who provide housework and personal care), andvisiting nurses ; home modifications ; the provision of assistive
devices for in-home services ; day care (including rehabilitationand short stay respite care outside the home) ; and nursing
homes, residences with medical services, and dementia grouphomes for institutional care.
In Japan’s long-term care insurance system, one care manager
is responsible for the person requiring care. The care manager
liaises with the patient and family caregivers and plans the services they need (2, 3). Additionally, as part of the medical insurance plan, doctors provide home visits to patients who are unable
to visit hospitals for physical or social reasons. The number of patients receiving home medical care is estimated to increase fromapproximately 700,000 in 2015 to around 1,000,000 by 2025 (4).
In a 2017 survey, many hospitalised patients reported family cooperation as an important factor in enabling home careand care services (5). However, caregivers generally reported
Received for publication February 7, 2023 ; accepted July 10, 2023.
Address correspondence and reprint requests to K. Tani, General
Medicine and Primary Care, Tokushima University Hospital, 50
Kuramoto-cho 2, Tokushima 770-8503, Japan and Fax : +81-88-6339687. Email : taniken0601@gmail.com

experiencing a higher frequency of anxiety and depression. In
a survey of a non-patient population in Japan (female students
and female administrative staff), 23.8% of participants reported
both anxiety and depression (6). A systematic review reported ahigh prevalence of depression and anxiety among caregivers ofcancer patients (42.3% and 46.5%, respectively) (7). A similar
trend has been observed among caregivers of non-cancer disease
patients, such as stroke patients (anxiety 43.9%, depression
53.9%) (8) and dialysis patients (anxiety 52%, depression 30.2%)(9). Reducing their anxiety and depression is necessary for quality home care ; thus, identifying the factors associated with these
disorders is helpful.
Factors related to anxiety and depression have been widely
investigated and reported for caregivers of patients with cancer(7, 10, 11), stroke (8), and dementia (12). Age, sex, health status,
financial factors, and social support have been reported to berelated to caregiver depression (7, 12), and sex, health status,and financial factors have been reported to be related to caregiver anxiety (8, 10, 11). However, few studies have examinedfactors in the home visit setting. This study aimed to assesscaregiver anxiety and depression and identify the associated factors through a survey of family caregivers of patients receiving
medical home visits.

PATIENTS AND METHODS
Study design

This cross-sectional study administered a questionnaire
survey to caregivers of patients receiving home visits. In April
2019, we referred to the Tokushima Prefecture website and local
medical associations for a list of medical institutions that provided home medical care ; 239 medical institutions were listed.
We requested cooperation from all of these medical institutions.
In May 2019, we mailed the study description and the

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Y. Okura, et al. Home caregiver anxiety and depression

questionnaire for caregivers (supplemental file 1) to the medical
institutions that agreed to cooperate with us. Physicians or nurses from the collaborating medical institutions used the study
description document to explain the study to family caregivers
and patients at regular visits and distributed the questionnaires
to them.
The questionnaires were returned using the enclosed returnenvelope for collection. Data were collected for a period of six
weeks, from 1 June to 12 July 2019. The investigation was conducted in accordance with the Declaration of Helsinki of 1975.
Written informed consent was obtained from all participants
and they answered the questionnaire anonymously.

Participants
Caregivers who regularly attended patients’ doctor visits, resided with the patient, lived separately but on the same premises
as the patient, or those who—though they lived independently—
visited the patient’s home at least once a week and were involvedin the patient’s care, were included in the study.

Data collection and measurement
This study assessed anxiety and depression using the 14-item
Hospital Anxiety and Depression Scale (HADS), a self-administered general outpatient anxiety and depression test (13).
Requiring about five minutes for completion, it is suitable for
utilisation in outpatient clinics and health check-ups wheretime is limited. Furthermore, it has been validated for use insettings outside hospital populations (6) and for caregivers ofhome healthcare patients (14). It has been translated into many
languages, and we employed the Japanese version developed byKitamura (15).
Several evaluation models have been proposed for HADS,
including the one- (16), two- (13, 17), and three-dimensional models (18, 19) ; most studies support the original two-dimensionalmodel. Because it has been validated for visiting caregivers ofpatients (14), we assessed participants in this study using theoriginal method. The questions were categorised into seven anxiety and depression items each and the responses were scored ona four-point Likert scale from 0–3, with the response options differing from item to item. For example, for one item they ranged
from ‘0 = always’ to ‘3 = never’, whereas for another they ranged
from ‘0 = occasionally’ to ‘3 = always’. Each response was summed
and scored on the HADS anxiety (HADS-A) and depression(HADS-D) subscales. In accordance with the original article (13)and previous studies (10, 11), we categorised the participants
who had HADS-A and HADS-D scores of 8 or higher into groups
with anxiety and depression, respectively.
We examined caregivers’ sociodemographic data comprisingsex, age, and employment status. For patients, we assessed sex,age, their relationship with caregivers, the level of care required
from the long-term care insurance, the number and type of diseases they had, and their region of residence.
The items related to caregivers’ perceptions of the home careenvironment, their patients, and themselves were ‘Stable family
finances’, ‘Stable health of caregiver’, ‘Stable condition of patient’,‘Confidence in emergency doctor visits’, ‘Confidence in emergency nurse visits’, ‘Confirmation of a hospital to be admitted toin case of emergency’, ‘Sufficient care services’, ‘Availability of
reliable advisors’, ‘Availability of other alternative caregivers’,and ‘Sufficient explanation and knowledge about home care’.
We scored how the caregivers felt using a five-point Likert scale(1 = totally disagree to 5 = very much agree).

Statistical methods
The sociodemographic characteristics of the patients and caregivers and the distribution of HADS were represented by the

number of people. Their ages and the caregiver perception scores
were expressed as means and standard deviations.
As noted, we categorised those with HADS-A and HADS-D
scores of 8 or higher into groups with anxiety and depression,respectively, and intergroup comparisons were made for both.
For univariate analysis, the chi-squared test or Mann–Whitney U test was conducted as appropriate for categorical variables
such as patients’ and caregivers’ sociodemographic factors andcaregivers’ perceptions.
For multivariate analysis, a multiple logistic regression analysis with forward stepwise selection (entry level 0.05, removal
level 0.10) was conducted to examine the factors associated with
anxiety and depression. The outcome variable was the presenceof anxiety or depression. The explanatory variables were sociodemographic factors and caregivers’ perceptions of factors forwhich associations were noted in previous studies, or for whichp < 0.1 was found in univariate analysis. The Hosmer–Lemeshow test was used to determine the suitability of fit. The significance level was set at p = 0.05.
The effect size r was calculated using the test statistic Z andthe sample size N, through the following formula (20) :A priori power analysis was conducted based on a predictedeffect size d of 0.5, an alpha value of 0.05, a power (1-β) of 0.8,
and an allocation ratio of 2.33, calculated by referring to previous studies and assuming a prevalence rate of 30% for anxiety
and depression. The target total sample size was set to 160
participants.
A priori power analysis was performed using G*POWER (ver.
3.1.9.4) (21). All other statistical analyses were performed using
the Statistical Package for the Social Sciences version 24 (IBMCorp., Armonk, NY, USA).

Ethical approval
This study was approved by the Tokushima University Ethical
Review Board for Medical Research (No. 3440).

RESULTS
In total, 105 medical institutions replied, of which 52 had nohome patients or refused to participate in the study. The remaining 53 medical institutions cooperated. Each of the collaborating
medical institutions selected family caregivers who met theeligibility criteria for participation, which together totalled 379
participants.
The questionnaire for family caregivers was distributed to the379 participants, of which 203 responded (response rate 53.6%).
Thirty of these responses contained blank spaces ; thus, they
were excluded. The final number of valid responses was 173(valid response rate : 85.2% ; 48 male and 125 female). The mean
age of the family caregivers was 66.2 ± 10.7 years, with a rangeof 33 to 90 years (Table 1).

Distribution of the HADS subscales
Regarding HADS-A, 97 (56.1%) and 76 (43.9%) participants
were in the non-anxiety (HADS-A ≤ 7) and anxiety groups,
respectively. Concerning the HADS-D, 53 (30.6%) and 120(69.4%) participants were in the non-depression (HADS-D ≤ 7)
and depression groups, respectively. Only 47 (27.2% of the total)
caregivers had neither anxiety nor depression (both HADS-A
and HADS-D ≤ 7). Of the anxiety group’s participants, 92.1%
also had depression (Table 2).

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The Journal of Medical Investigation Vol. 70 August 2023

Table 1. Comparison between 173 patients’ and 173 caregivers’ sociodemographic characteristics and the Hospital Anxiety and Depression
Scale

Area

ALL

Non-Anxiety
group(HADS-A ≤ 7)

Anxiety group(HADS-A ≥ 8)

Depopulated area : 38

23

15

others : 13574

61

66.2 ± 10.7

66.7 ± 10.7

65.6 ± 10.8

Male : 48

30

18

Female : 125

67

58

Age : mean ± SD
Sex : nCaregiver

31

30

66

46

Relationship with
Patients : n

Spouse : 53

29

24

Other : 120

68

52

Age : mean ± SD

81.8 ± 15.3

81.5 ± 17.0

82.1 ± 13.1

Male : 67

35

32

Female : 106

62

44

0 / 1 : 68

42

26

2 : 39

24

15

3: 39

21

17

4 ≤ : 2710

17

Number of
Diseases : n

0.56
0.29

Employed : 61

Sex : n

Non-Depression Depression
group
group
(HADS-D ≤ 7)
(HADS-D ≥ 8)

0.53

Unemployed : 112

Job : np-Value

0.31
0.81
0.59
0.42

0.045

12

26

41

94

68.0 ± 9.8

65.4 ± 11.0

15

33

38

87

18

43

35

77

15

38

38

82

84.0 ± 13.0

80.8 ± 16.2

19

48

34

72

20

48

12

27

14

25

7

20

42

89

11

31

Clinic : 131

74

57

Hospital : 42

23

19

Unfilled : 8

4

4

2

6

Unapplied : 11

8

3

5

6

RS 1 : 4

3

1

0

4

RS 2 : 8

4

4

2

6

Home Doctor : n
Patient

Level of Care
Required in
LTCI : n

0.84

RLTC 1 : 9

8

1

8

1

RLTC 2 : 24

12

12

7

17

RLTC 3 : 35

18

17

10

25

RLTC 4 : 32

15

17

8

24

RLTC 5 : 42

25

17

11

31

0.43

p-Value

0.89
0.09
0.91
0.81
0.66
0.19
0.61

0.81

0.47

0.12

Note : The p-values were calculated using the Mann–Whitney U test for the caregivers’ and patients’ ages, number of diseases, and levelof care ; the chi-squared test was employed for the others.
Abbreviations : HADS-A : Hospital Anxiety and Depression Scale-Anxiety ; HADS-D : Hospital Anxiety and Depression Scale-Depression ; LTCI : Long-Term Care Insurance ; RLTC : Requiring Long-Term Care ; RS : Requiring Support ; SD : Standard Deviation.

Table 2. Results of cross-tabulation of anxiety/depression subscales of 173 caregivers in Japan (2019)
Non-Depression group : n(%)(HADS-D ≤ 7)

Depression group : n(%)(HADS-A 8)

Total : n (%)

Non- Anxiety group : n(%)(HADS-A ≤ 7)

47 (27.2%)

50 (28.9%)

97 (56.1%)

Anxiety group : n(%)(HADS-A ≥ 8)

6 (3.5%)70 (40.5%)

76 (43.9%)

Total : n n(%)

53 (30.6%)

120 (69.4%)

173 (100%)

Abbreviations : HADS-A : Hospital Anxiety and Depression Scale-Anxiety ; HADS-D : Hospital Anxiety andDepression Scale-Depression.

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Univariate analysis
The sociodemographic characteristics of the patients andcaregivers were examined for associations with anxiety anddepression in the univariate analysis (chi-square test or theMann–Whitney U test). The results showed that the numberof illnesses in patients was significantly associated with anxiety ; however, no items were related to depression (Table 1).
The patients’ disease types are shown in Figure 1. The relation
between the presence of diseases and anxiety/depression was
analysed using the chi-square test for each disease ; however,no significant differences were found for any of the diseases ineither subscale.

Regarding caregivers’ perceptions, five items were associatedwith anxiety : stable family finances, stable caregiver health,stable patient condition, sufficient care services, and sufficient
explanation and knowledge about home care. Eight items wereassociated with depression : stable family finances, stable caregiver health, stable patient condition, confidence in emergency
doctor visits, confidence in emergency nurse visits, sufficient
care services, availability of reliable advisors, and sufficient
explanation and knowledge about home care. No association wasobserved between HADS and the confirmation of a hospital to be
admitted to in case of emergency, or availability of other alternative caregivers (Table 3).

Figure 1. Type of diseases of 173 Japanese patients receiving home visits

Table 3. Univariate analysis between 173 Japanese caregivers’ perceptions of the home health care situation and anxiety/depression
Questionnaire items

Non-Anxiety
group(HADS-A ≤ 7 )vsAnxiety group(HADS-A ≥ 8)

p-Value

Non-Depression
group
vs(HADS-D ≤ 7)

Stable family finances

3.7 ± 1.0

vs2.8 ± 1.1

< 0.001

3.9 ± 0.9

Depression
group(HADS-D ≥ 8)

p-Valuevs3.1 ± 1.1

< 0.001

Stable caregiver health

3.7 ± 0.8

vs2.8 ± 1.1

< 0.001

3.8 ± 0.8

vs3.1 ± 1.1

< 0.001

Stable patient condition

3.9 ± 0.7

vs3.4 ± 1.0

< 0.001

4.0 ± 0.8

vs3.5 ± 0.9

< 0.001

Confidence in emergency doctor visits

3.9 ± 1.1

vs3.7 ± 1.1

0.144

4.1 ± 0.9

vs3.7 ± 1.1

0.012

Confidence in emergency nurse visits

3.9 ± 1.0

vs3.6 ± 1.1

0.082

4.0 ± 1.1vs3.6 ± 1.1

0.041

Confirmation of a hospital to be
admitted in case of emergency

3.4 ± 1.1vs3.6 ± 1.1

0.154

3.4 ± 1.2vs3.6 ± 1.1

0.404

Sufficient care services

4.0 ± 0.8

vs3.6 ± 0.9

0.002

4.1 ± 0.8

vs3.7 ± 0.9

0.019

Availability of reliable advisors

3.9 ± 1.0

vs3.7 ± 0.9

0.094

4.2 ± 0.8

vs3.7 ± 1.0

< 0.001

Availability of other alternative
caregivers

3.4 ± 1.2vs3.3 ± 1.4

0.627

3.6 ± 1.3vs3.3 ± 1.3

0.089

Sufficient explanation and knowledge
about home care

3.8 ± 0.8

vs3.4 ± 1.0

0.004

3.9 ± 0.9

vs3.5 ± 0.9

0.012

Note : The table includes the mean ± standard deviation of each group and p-values were calculated using the Mann–Whitney U test.
Abbreviations : HADS-A : Hospital Anxiety and Depression Scale-Anxiety ; HADS-D : Hospital Anxiety and Depression Scale-Depression.

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Multiple logistic regression analysis
We performed a multiple logistic regression analysis to adjust for potential confounders. The outcome variable was thepresence of anxiety or depression. The explanatory variables foranxiety were two sociodemographic factors (sex of caregivers andnumber of patients’ diseases) and seven caregiver perceptions(stable family finances, stable caregiver health, stable patient
condition, confidence in emergency nurse visits, sufficient careservices, availability of reliable advisors, and sufficient explanation and knowledge about home care). The explanatory variables
for depression were two sociodemographic factors (age of caregivers and sex of caregivers) and nine caregiver perceptions (stablefamily finances, stable caregiver health, stable patient condition,
confidence in emergency doctor visits, confidence in emergency
nurse visits, sufficient care services, availability of reliable advisors, availability of other alternative caregivers, and sufficient
explanation and knowledge about home care). The results arelisted in Table 4. Effect sizes were calculated for the items that
demonstrated significant associations.
We found that two items were associated with anxiety : stablefamily finances (effect size 0.38, moderate effect) and stable
health of caregivers (effect size 0.42, moderate effect). Three
items were associated with depression : stable family finances(effect size 0.33, moderate effect), stable health of caregivers(effect size 0.38, moderate effect), and stable condition of patients(effect size 0.26, slight effect).

DISCUSSION
In this study, 43.9% and 69.4% of caregivers providing home
visits were found to have anxiety and depression, respectively.
Similar to caregivers of cancer patients and stroke patients,
the results of this study suggest that caregivers providing home
visits have a high prevalence of and are at risk for both anxiety
and depression. Past studies have found differences in the prevalence of anxiety and depression. In this study, depression was
more prevalent than anxiety, which may reflect its prevalence inthe general population. According to the 2017 Japanese Patient
Survey (22), the number of patients with mood disorders (including depression) was higher than that of patients with neurotic
disorders such as anxiety. This is especially true among older
adults. Because the participants in this study were older caregivers averaging over 66 years of age, this may explain why theprevalence of depression was higher than that of anxiety.
In this study, the factors associated with anxiety were : 1) stable family finances and 2) stable caregiver health, while the factors associated with depression were : 1) stable family finances,
2) stable caregiver health, and 3) stable patient condition. The association between these factors and anxiety/depression has beenreported in previous studies. A study in France reported thatcaregivers’ financial difficulties were negatively correlated withdepression (11) ; however, many studies have shown a positive
relationship between the two variables (10, 23, 24). Long-term
medical care requires money, and when caregivers are placed
under an additional financial burden, it may result in increased
depression owing to psychological stress (8). Good health is important for caregivers, and this study suggests that the same istrue in the home health care setting. Some studies suggest thatpoor health reduces physical and mental resources and affects
susceptibility to depression and anxiety (23, 25), while otherssuggest that depression contributes to poor physical functioning(26). The association of depression and anxiety with patients’poor health has been reported in several studies (24, 27). Studies
on caregivers of terminal cancer patients have shown that, as
the patient’s illness worsens, the emotional burden of caregiving
increases and depression worsens. However, providing education
about the patient’s deterioration and death can improve anxiety,depression, and sleep quality (28). Thus, support for caregivers is
especially important if the patient’s condition is unstable.
The results of this study offer the following suggestions forhome health care providers to reduce caregiver anxiety anddepression. First, it is important to try to lower medical andlong-term care costs to ensure stable family finances. Reducing
medical costs by eliminating unnecessary tests and treatments
may reduce the cost burden on patients and lower anxiety anddepression among caregivers. Additionally, active inter-professional work with medical social workers or government agencies
may be effective in helping patients and caregivers access publicsocial support services that can lower various financial burdens.
Second, paying attention to the caregiver’s health and providing
comprehensive care will improve the caregiver’s physical andmental health, which will in turn be beneficial for the patient
as well.
Many studies have also cited age as a factor related to anxiety and depression ; however, no such association was found in
this study. The reason for this remains unclear. Moreover, nosignificant sex difference was observed ; however, this may be acharacteristic of the Japanese population. Although several previous studies have reported that female caregivers have higher
anxiety and depression (8, 10, 12, 24, 26), a survey of Japanese
caregivers found no differences based on sex (29, 30). Although
the incidence of depression is generally greater in females (31),no difference was observed between male and female caregivers
in Japan, suggesting that Japanese men may be relatively moresensitive to the burdens of caregiving and thus be at an increased risk of experiencing higher anxiety and depression (30).
Regarding the association between age and anxiety/depression, previous studies reported conflicting results. Multiple
studies of cancer patients’ caregivers have consistently indicated negative associations (10, 11, 23, 32), while those involving

Table 4. Multiple logistic regression analysis of factors associated with anxiety and depression among 173 caregivers in home visits in Japan
Anxiety

Depression

OR

95% CI

p-Value

Effect sizeOR

95% CI

p-Value

Effect size

Stable family finances

0.57

0.41 - 0.81

0.002

0.38

0.57

0.37 - 0.88

0.011

0.33

Stable caregiver health

0.47

0.32 - 0.67

0.001

0.42

0.44

0.26 - 0.73

0.001

0.38

0.53

0.29 - 0.95

0.035

0.26

Stable patient condition
Hosmer–Lemeshow test

χ2 = 4.25 ; df = 3 ; P = 0.24

χ2 = 5.97 ; df = 6 ; P = 0.43

Predictive accuracy 76.8%

Predictive accuracy 75.6%

Abbreviations : 95% CI : 95% Confidence Interval ; OR : Odds Ratio.

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Y. Okura, et al. Home caregiver anxiety and depression

chronically ill patients’ caregivers have found positive associations (26). This discrepancy may be due to differences in patients’
illness characteristics. Specifically, cancer patients’ caregivers
are exposed to the stress of possibly losing the patient owing to
the serious nature of the illness ; nevertheless, younger caregivers are more depressed than older ones because attachment
anxiety is stronger in younger generations (32). Alternatively,
chronically ill patients’ caregivers are reported to have increased
depression due to the stress of declining physical functions andan increasing care burden as they age (26). In our study, patients
receiving home visits had a wide variety of diseases, including
cancer and chronic illnesses ; the variety of diseases may haveconfounded the results, resulting in no significant difference.
Furthermore, it has been shown that social support is related
to lower depression (7, 27, 29, 33), and the role of medical institutions as part of the support system is significant. This study, although limited to univariate analysis, suggested that the on-callsystem of doctors or nurses in emergencies might reduce depression among caregivers. This is an important result regarding thekind of services that should be provided by medical institutions.
Further research is required in this area.
Our study has several limitations. First, it was a cross-sectional study ; thus, the causal relationship between the related
items and anxiety/depression is unclear. Second, because thequestionnaires were returned by the caregivers themselves, data
were only collected from cooperative participants. It is possiblethat those with high anxiety or depression could not or may nothave completed the questionnaire. Third, the number of years
of care may be an important factor, but we did not examine it inthis survey. We will look into this in a future survey. Furthermore, this study only included caregivers from one city in Japan.
Therefore, the results cannot be generalised to all caregivers ofpatients at home, and the data should be interpreted with caution. Furthermore, because we did not investigate the caregivers’
detailed medical history, we cannot ignore the likelihood that the
caregivers’ mental illness and treatment may have affected thepresent results.
Despite these limitations, this is the first study to investigate
the factors associated with anxiety and depression among caregivers of patients receiving home visits from a number of medical
institutions, and it provides important findings for home visit
medical care.

CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.

ACKNOWLEDGEMENTS
The authors thank the staff at the home health care institutions in Tokushima Prefecture for their cooperation, and Ms.
Yayoi Tagawa for her valuable secretarial support.

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