Abstract
Background
Most children with cancer want clear and honest information about their illness, and effective communication can support coping and reduce distress for children and families. However, in Japan, healthcare professionals face numerous communication barriers when discussing cancer diagnoses with children, and the culturally grounded beliefs and approaches shaping these conversations remain poorly understood.
Objectives
This study was aimed at clarifying the beliefs and approaches of Japanese healthcare professionals in communicating cancer diagnoses to children and their families.
Design
An exploratory qualitative design was adopted, involving semi-structured individual interviews.
Methods
Participants included 18 healthcare professionals (9 physicians and 9 nurses) with over seven years of experience. Data were analyzed using thematic analysis.
Results
Five approaches were identified under an overarching commitment to the child’s best interests: 1) honesty balanced with emotional protection, 2) empathetic negotiation with families, 3) information sharing to ensure understanding and hope, 4) being present in suffering, and 5) professional self-reflection and mutual team support. While these themes resonate with international literature on honest and supportive communication, two culturally salient features emerged in Japan: a strong tendency to prioritize families’ wishes in decision making and a relational emphasis on “being present” rather than relying solely on structured, protocol-driven conversations. Communication was hampered by a lack of standardized training and a shortage of pediatric oncology nurses due to staff rotation.
Conclusions
Pediatric cancer diagnosis communication in Japan is shaped by five approaches that prioritize the child’s best interests. Locally grounded strategies highlight the importance of trust, relationship building, and being present, but may limit children’s voices when family preferences dominate. It is essential to employ nurses who specialize in pediatric cancer care. Future research should incorporate the children’s and families’ perspectives and evaluate culturally sensitive communication strategies.
Plain language summary
When a child is diagnosed with cancer, honest and supportive communication can help the child and family cope with fear and uncertainty. Many children want clear information about their illness, but it can be difficult for parents and healthcare professionals to decide what to say, when to say it, and how much to tell. In Japan, cultural values such as keeping family harmony and protecting children from distress often shape these conversations, but little is known about how doctors and nurses actually think and act in these situations. In this study, we interviewed 18 experienced pediatric oncologists and nurses in Japan about their beliefs, worries, and usual practices when explaining a new cancer diagnosis to children and their families. We found that they tried to be honest while protecting children’s emotions, worked closely with parents, and focused on sharing information in ways that supported understanding and realistic hope. They also emphasized “being there” for children and families and supporting each other as a team. Doctors and nurses described doing their best for the child within cultural and institutional constraints, but they felt that limited communication training and frequent nurse rotation made it hard to build and maintain specialist skills. Supporting structured communication training and helping nurses remain in pediatric oncology may be important steps toward more consistent, child‑centred communication from the time of diagnosis.
Keywords
Introduction
Most children diagnosed with cancer feel the need to be continuously informed and, therefore, seek clear and frequent information regarding their diagnosis and prognosis.1–3 Effective communication promotes coping with diseases, reduces stress and anxiety, and improves relationships among children, families, and healthcare professionals.4,5
Palliative care is administered to alleviate the suffering of children and their families and to maintain or improve their quality of life throughout the illness trajectory. 8 According to international definitions, pediatric palliative care should begin at diagnosis and continue alongside disease-directed treatment. Timely, developmentally appropriate communication about illness and its treatment is therefore central to this approach. 8
However, despite the growing recognition of children’s right to be informed, various factors make it challenging for families and healthcare professionals to convey information about cancer to their children. Recent studies have highlighted that healthcare professionals worldwide continue to struggle to deliver cancer diagnoses to children due to knowledge gaps, insufficient training, and a lack of evidence-based guidelines.4,6 A recent systematic review confirmed that communication in pediatric oncology remains a significant global challenge, marked by barriers at the individual, interpersonal, and institutional levels. 7 Another study suggested six levels of barriers: individual, team, organization, collaborating hospital, community, and policy. 6 Although previous studies have delineated communication barriers, the underlying belief systems and interpretive frameworks that guide professionals’ communication choices remain underexplored. Understanding these decision-making logics is critical for developing interventions that address not only “how” but also “why” communication practices unfold as they do.
Communication in pediatric oncology is influenced by the cultural context. In Japan, where communication often prioritizes group harmony (wa) and implicit understanding over direct discourse, information sharing and decision-making are frequently moderated by parental preferences.9,10 Consequently, communication with children may be limited or indirect. Despite growing global interest in culturally sensitive communication, little is known about how Japanese healthcare professionals interpret cultural values in actual communication practices. Therefore, understanding the specific strategies and underlying beliefs that guide Japanese healthcare professionals when communicating with children about cancer diagnosis is crucial for designing culturally adaptive training and support programs.
This study aimed to clarify the underlying beliefs and approaches used by healthcare professionals when communicating with children with cancer and their families regarding their cancer diagnosis. Going beyond the “disclosure rate” and “amount of information” emphasized in prior quantitative research, this study explores the logic of professional judgment underlying their communication strategies. These findings are expected to inform the development of culturally adaptive communication strategies and evidence-based training programs.
Methods
Design
This study employed an exploratory qualitative research design using semi-structured interviews. Reporting of this study followed the Consolidated Standards for Reporting Qualitative Research (SRQR) guidelines (Supplementary file 1).
Operational definition
In this study, “communication” was defined as the disclosure of cancer diagnostic information and subsequent interpersonal dialogue among children diagnosed with cancer, their families, and healthcare professionals.
Participants
The research participants were physicians and nurses with >7 years of experience as healthcare professionals. According to Benner’s (1982) theory of nursing experience, individuals are classified into five stages: novices (<1 year), advanced beginner (1–3 years), competent nurse (3–5 years), proficient nurse (5–7 years), and experts (>7 years). In this study, individuals with >7 years of experience in pediatric cancer care were targeted to gather insights from expert pediatric oncologists. No exclusion criteria were considered.
As this was an exploratory qualitative study, a formal statistical power calculation was not performed; instead, the sample size was guided by the trajectory equifinality model and the principle of obtaining information-rich cases. To derive the typologies of the study participants, the sample size was determined to be 9 ± 2 for both physicians and nurses. 11
Data collection
Purposive sampling was used to recruit healthcare professionals with sufficient experience in communicating with children with cancer and their families from June 2024 to June 2025. The participants were selected using snowball sampling. Prospective participants were provided with the research protocol in advance. Upon reading and agreeing to participate online, they were first required to provide information about their demographics (including age, years of experience, job role, and qualifications) and the facility in which they currently worked (such as type of healthcare facility). On the day of the interview, participants received another briefing from the researcher, and the interview was conducted only if they agreed to participate.
Approximately 1 h of semi-structured online interviews were conducted (range: 54 min to 1 h 16 min) following a pre-specified interview guide (Supplementary file 2). It was developed by the research team based on the literature review of communication in pediatric oncology and pediatric palliative care and refined through discussions with experts in pediatric oncology and family nursing. The guide was not pilot-tested. Data on accelerating factors and barriers related to communication with children and their families and their needs were collected following the interview guide. During the interviews, recordings were made with the participants’ consent.
Positionality statement
The first author was a pediatric nurse and researcher experienced in working with children with cancer and their families. This professional background indicated their familiarity with the clinical context and sensitivity when engaging with the participants. Simultaneously, the author maintained a reflexive awareness of how prior clinical experiences and beliefs shape interpretations of communication processes. Throughout the study, reflexive journaling and discussions among the research team were used to critically examine how the first author’s professional lens influenced data interpretation and theme development.
Data analysis
Data were analyzed using thematic analysis following Braun and Clarke’s six-step approach, 12 supported by MAXQDA24 (https://www.maxqda.com/new-maxqda-24). Thematic analysis provides a systematic yet flexible framework for identifying, analyzing, and interpreting patterns of meaning in qualitative data. Following Braun and Clarke’s reflexive model, the process began with thorough familiarization with the data through repeated reading and note-taking to gain an in-depth understanding of the participants’ accounts. Next, meaningful data segments were inductively coded to capture the features relevant to the research questions. These codes were grouped into broader themes that reflected the recurring patterns or underlying ideas observed across the dataset. Potential themes were reviewed and refined to ensure internal coherence and distinctiveness, while maintaining alignment with the dataset. Each theme was clearly defined and named to convey its conceptual essence and contribution to the study’s aims. Finally, the analysis was conducted by integrating illustrative data excerpts with an interpretive commentary that contextualized the themes within the existing literature and theoretical perspectives. A detailed coding framework summarizing the main codes, their definitions, and their mapping onto themes is provided in Supplementary file 3 to facilitate the transparency and potential use of our analytic structure in future studies. The final set of themes generated through this process is summarized in Table 2. This reflexive and iterative process emphasized the researcher’s active role in interpreting meaning, rather than treating themes as passively emerging from the data. 12 To prevent bias, the themes and codes were validated through team discussions and reflections (reflexivity). Reliability and validity were enhanced through consultation with pediatric oncology researchers, and key interpretations were confirmed (member-checked) by the interviewees to ensure accuracy and credibility.
Ethical considerations
The study was conducted in accordance with the principles of the Declaration of Helsinki. All procedures used in this study were approved by the Ethics Committee of Showa Medical University (approval number: 2024-071-A), ensuring compliance with ethical standards and guidelines. Prior to participation, all participants received detailed study information online and provided their informed consent electronically through a secure web-based platform. The consent process included confirmation that participation was voluntary and that participants could withdraw at any time without penalty. Ethical rigor was ensured by maintaining confidentiality, anonymizing all data, and storing digital records on password-protected servers accessible only to the research team.
Results
Participant characteristics
Characteristics of participants.
Main findings
Theme summary: Healthcare professionals’ beliefs and approaches to communicating cancer diagnosis to children and their families.
Theme 1. Honesty balanced with emotional protection: Supporting emotional well-being while being honest
All professionals believed that information about the diagnosis should be shared with children, expressed the belief that “children should not be lied to,” and placed a strong emphasis on honesty. They avoided causing unnecessary harm and addressed difficult questions by exploring their emotional context before responding. The participants responded as follows: “If possible, and if the child’s condition is good, I really want to talk with them about their illness before starting full-scale chemotherapy. Of course, if it’s a difficult disease to cure, or if the child is feeling too unwell, sometimes it’s not possible (Doctor 8).” “I really do not want to lie to children. I don’t disclose prognosis unnecessarily, but if the child asks, like, ‘Am I going to die?’ or ‘Will I get better from this disease?’ I first tried to understand why they thought that. If the situation allows, I provide an honest answer. I avoid being vague or hiding things when asked directly; I think not lying, not hiding, is important (Doctor 4).”
The participants stated that the content, timing, and setting were tailored to the children’s and families’ conditions and emotional readiness, often through gradual individualized disclosure. “There is really no need to tell everything in advance, but I think it is important to match each explanation and approach to the individual circumstances and how each child can accept it. Honestly, it is not something where there is just one simple answer; there are no hard and fast rules that apply to everyone. It depends on the family, the situation the child is in, their age, and how they think. I feel that this is something that needs to be adapted to each and every person (Nurse 7).”
This theme was reflected in the gradual, tailored disclosure approach, with thoughtful planning regarding when, what, and how information was conveyed, always balancing the principle of truth-telling with the imperative of avoiding unnecessary psychological harm.
Theme 2. Empathetic negotiations with families: Balancing parental wishes and professional recommendations
Theme 2 illustrates how healthcare professionals view families as children’s primary supporters and seek to build close, empathetic relationships with them. Decisions regarding disclosure were made jointly, accounting for parents’ readiness and knowledge. One participant stated that they strived to engage in interpersonal dialogue that went beyond their roles as healthcare professionals. “We discuss with parents about what to do; if the parents bring the child in and ask us to talk to them directly, we talk together. But if a parent says, ‘Let me talk to my child first,’ then I tell them, ‘Please make sure to accurately explain what’s going to happen next (Doctor 9).”
Professionals recognized that parents needed time and space to process information and their own emotions before being able to help their child absorb the news. “First, I tried to find out how the parents understood the current situation. Sometimes, even the doctor isn’t aware of that, so I make it a point to let the doctor know, like, ‘The parents see the transfer to this hospital as meaning this.’ I try to bridge that gap whenever I can (Nurse 3).” “When a child has a reaction, I think it’s actually the parents— the family— who are going to support them. Therefore, when parents are unprepared, it is difficult to explain things to the child. Unless the parents are ready, I don’t think we can proceed with telling the child (Doctor 1).”
They were attuned to the importance of adjusting explanations, sometimes based on the family’s preference for terminology or unique situations. “Regarding word choice, I consult with the mother and father in advance; should I say ‘cancer,’ or use ‘growth,’ or ‘tumor,’ or accommodate special requests, or if the grandmother had cancer, that could impact what words to use. We talk and then adjust the way we explain accordingly (Nurse 4).”
This theme captures the practice of empathetic negotiation, an adaptive relationship-building approach in which healthcare providers actively balance parental authority and professional guidance, always aiming to support the family as a unified team for the child’s well-being.
Theme 3. Information sharing to ensure understanding and hope: Providing clear information that supports hope, even with bad news
The belief that comprehensible and hopeful communication prevents self-blame and promotes effective coping is critical. Healthcare professionals frequently monitored misunderstandings and provided supportive explanations to prevent families and children from thinking that the illness or procedures were their fault. Their communication aimed at ending difficult discussions with hope or reassurance. “First, when a tumor is suspected, the treatment methods differ significantly depending on the specific disease; therefore, we only decide on the exact treatment and length of hospitalization after the diagnosis is confirmed. I usually start by saying that, compared to adult cancers, many childhood cancers are more likely to be cured, so being hopeful is the main message I give at the beginning (Doctor 6).”
Healthcare professionals also described using clear tools and age-appropriate language to help families and children better understand their circumstances, sometimes using illustrated materials developed by hospitals, and sometimes with team input. “For preschoolers, for example, we might work with a teacher or psychologist using hospital-made materials. Depending on the case, it’s usually the doctor who explains things, but with older children, we’ll often have the doctor and nurse consult with the family and time things together (Nurse 9).”
They provide children and families with clear and concrete outlooks and coping strategies to maintain hope. “For instance, letting a child know they could still study while in the hospital, or that they’d have classmates to play with, made a huge difference for children of school age. When it came to losing hair, I realized that many children did not feel out of place among their peers in the hospital, but it could hit them when they returned to their regular school. Being able to affirm that this is normal and provide support through similar experiences with peers really matters (Nurse 1).”
Participants emphasized intentionally ending even difficult conversations with hope and reassurance to help children and their families navigate treatment while avoiding excessive optimism or unnecessary despair.
Theme 4. Being present in suffering: Sharing time in compassionate communication
Theme 4 highlighted the belief that children and families should never feel alone during times of physical distress, disease progression, or end-of-life situations. Presence through play, conversation, and physical/emotional support extended beyond medical interventions. Participants described making time to be with children and their families, recognizing that such ordinary acts were crucial for relationship building and helping children share their fears or struggles. One participant stated the following: “Spending time together through play, care, and showing interest in what the child likes naturally deepens the relationship. That is when a child might start talking about difficult things, not just their illness. That’s how communication grows (Nurse 6).”
Healthcare professionals stated that communication occurred through a continuous, playful presence, especially for young children. “With younger kids, I just keep playing with them. If they are feeling okay, I take them to the playroom, and we play there for as long as they want. Yes, sometimes I have to do things they do not like—give medicine and place an IV—but it’s important for them to know that I am not just someone who does bad things to them. That is why I make time to go and play together, or if they are crying, to stay by their side as much as possible. Sharing those moments is essential for opening communication (Nurse 1).”
Even amid busy clinical schedules, healthcare professionals prioritized creating a space for informal interactions, knowing that both small talk and sitting quietly together could be meaningful, especially during critical conversations or difficult news. “Everyone is busy, but it is better not to have difficult conversations when you are overloaded. You need to ensure that you have enough time to face the patient. Even just chatting—making time for that can make all the difference (Doctor 1).”
These empathetic practices were considered central to building a sense of safety and belonging for children and their families, and as the foundation for effective and humane communication, regardless of the clinical context.
Theme 5. Professional self-reflection and mutual team support: Mutual team support through reflection and shared care
Theme 5 highlights healthcare professionals’ deep sense of professional responsibility and recognition that optimal care for children with cancer and their families requires multidisciplinary collaboration. The underlying belief is that children and families benefit most when supported from multiple perspectives and that the team’s collective effort is essential for safety, continuity, and emotional adaptation. One nurse described: “We have regular case conferences as soon as a new patient is admitted, where we share information about the family and discuss approaches. Every week, a multidisciplinary conference is held. Various staff members, including social workers, CLS (child life specialist), doctors, nursery teachers, pharmacists, and others, attend to share impressions and discuss issues. Afterward, we follow up together, so we’re always discussing and evaluating together as a team (Nurse 7).”
Medical professionals also reflect on the unique pressures of their roles, including accountability, emotional demands, and sadness, which can lead to difficult outcomes. One participant noted: “I think doctors, in particular, have to take the initiative. We shoulder big responsibilities, but at the same time, everyone has different expertise: social work, nursing, and child life, and it is important for people to contribute their strengths so that we can support kids and families from all possible angles. To me, it’s a great thing simply to know there are people who care, and that also connects to safety for everyone (Doctor 5).”
Participants noted that many facilities rotated nurses across multiple departments, resulting in a shortage of nurses specializing in pediatric oncology care. “In our hospital, especially in pediatrics, we have some staff who specialize in working with children, but many come in on rotation from various departments, so there are also staff who don’t know much about pediatric nursing. When caring for children with cancer, I think education is important—not that there’s always one right answer, but that it is necessary to keep learning about ways of interacting, current challenges, and how to build skills in those areas. I believe this kind of learning and engagement itself can be a catalyst for better care with children (Nurse 7).”
This theme was marked by an ongoing commitment to self-reflection, seeking colleagues’ perspectives, and fostering a professional environment in which each team member’s voice is valued.
Underlying all themes was the pursuit of the children’s best interests. While the professionals shared core values, specific approaches varied, reflecting individual experiences and institutional cultures. These variations stem from the absence of standardized nationwide training and communication curricula in Japan.
Discussion
This study clarified the underlying beliefs and approaches guiding pediatric oncology communication in Japan, identifying five themes: honesty balanced with emotional protection, empathetic negotiation with families, information sharing to ensure understanding and hope, being present in suffering and sharing together through difficult times, and professional self-reflection and mutual team support. These approaches are broadly consistent with international literature that emphasizes honest, supportive, and family-focused communication in pediatric oncology,1,13–15 yet they reflect distinctive cultural patterns in Japan. Two key Japanese features that emerged were particularly notable: strong prioritization of family preferences in decision-making and the centrality of “being present” as a relational form of support beyond explicit information-giving. In terms of all five themes, physicians and nurses did not differ in their underlying beliefs about children’s right to honest and supportive communication; they expressed these shared values through complementary roles that they clearly recognized and respected in one another. Physicians described taking primary responsibility for leading diagnostic disclosure and structuring key explanations, while nurses emphasized continuous bedside presence and emotional follow-up, thus supporting families and children as they absorbed and revisited the information over time.
Respect for family preferences has been described in family-centered decision-making frameworks globally 1 ; however, it appears especially pronounced in the Japanese context, where physicians frequently adapt their recommendations to parental values, even when these diverge from their own professional judgment. 16 The family-first stance arises from the belief that parents are the primary advocates for children’s well-being and most important partners in care. Similar tensions have been described in other cultural contexts. Qualitative work from Türkiye, for example, has shown that cultural and religious norms, protective parental attitudes, and communication taboos around cancer and death can lead parents and healthcare professionals to limit or delay direct disclosure of diagnosis and prognosis to children, particularly when the expected course of illness is poor. Along with our findings, this finding suggests that strong family-centered norms can protect children from distress and, at the same time, risk constraining their opportunities to receive information and express their own views.17–19 Our findings suggest that Japanese healthcare professionals are aware of this tension and seek to involve children through developmentally appropriate explanations and participation when possible; however, family wishes and cultural norms may still overshadow children’s voices. 20 To move closer to truly child-centered care, teams may need to intentionally create moments to ask, “What does this child want or need right now?” and make space for children’s preferences within family-centered discussions.
The emphasis on “being present” also emerged as a salient feature of Japanese pediatric oncology practice. Rather than focusing solely on structured conversations or protocol-driven communication, professionals highlighted the importance of sharing ordinary time with children and families, sustaining trust, and accompanying them through suffering without always having a concrete informational goal. This relational, presence-based model resonates with studies showing that rapport and relationship-building are closely linked to communication satisfaction and adjustment 15 ; however, it appears less formalized and more experiential compared to certain Western models that prioritize structured communication training and standardized protocols.15,21 In our participants’ accounts, playing with children was primarily described as a way of building rapport, and creating a sense of normality and security conducive to sharing their worries. Nonetheless, these practices align with evidence that structured therapeutic play can reduce fear and anxiety and serve as an important tool for communication with children.22,23 Our results suggest that, in Japan, relational continuity and everyday interactions may play a key role in helping families tolerate uncertainty and process difficult information over time. 14
Finally, this study revealed systemic challenges that shape communication in practice. Rather than being reliably developed through routine clinical experience alone, communication skills require structured and culturally tailored training; however, such opportunities remain limited and nurse rotation systems further hinder the development and retention of pediatric oncology nursing expertise. These organizational factors may contribute to variability in communication quality between institutions and constrain teams’ ability to provide consistent, specialized support. Addressing these structural issues, including the establishment and dissemination of formal communication training programs and strategies to retain specialized nurses, will be essential for strengthening pediatric oncology communication nationwide.5,24,25
Implications for palliative care practice and research
In summary, this study demonstrates that pediatric oncology communication in Japan is shaped by a family-first approach rooted in national values and care based on building interpersonal relationships beyond the medical-professional framework. Furthermore, such knowledge and skill are experience-dependent and may vary across institutions. Culturally sensitive team-based communication training must be developed in Japan to improve communication among pediatric patients with cancer, their families, and medical professionals at the national level.
Future research should investigate the perspectives of children and families alongside those of healthcare professionals, to comprehensively understand how all stakeholders experience communication processes. Moreover, comparative studies across different cultural and healthcare settings would help clarify which aspects of the Japanese experience are context-specific and which may offer transferable insights for pediatric oncology communication globally.
Conclusion
This qualitative study explored beliefs and communication approaches regarding cancer diagnosis among children and families, as reported by experienced physicians and nurses in Japan. The findings indicate that communication is supported by five approaches based on pursuing a child’s best interests: 1) honesty balanced with emotional protection: supporting emotional well-being while being honest; 2) empathetic negotiation with families: balancing parental wishes and professional recommendations; 3) information sharing to ensure understanding and hope: providing clear information that supports hope, even with bad news; 4) being present in suffering: sharing time in compassionate communication; and 5) professional self-reflection and mutual team support: mutual team support through reflection and shared care. While healthcare professionals’ beliefs were similar, the approaches varied according to individual and institutional cultures. Retaining specialized nurses is essential for strengthening communication and team-based pediatric oncology care in Japan. Future research is needed to further explore children’s and families’ perspectives on cancer diagnosis communication and incorporate their voices into the development of communication strategies tailored to different cultural backgrounds.
Supplemental material
Supplemental material - Communicating cancer diagnoses with children in Japan: A qualitative study of healthcare professionals’ beliefs and approaches in pediatric oncology
Supplemental material for Communicating cancer diagnoses with children in Japan: A qualitative study of healthcare professionals’ beliefs and approaches in pediatric oncology by Noyuri Yamaji, Nobuyuki Yotani, Mari Ikeda, and Takeshi Hasegawa in Palliative Care and Social Practice.
Supplemental material
Supplemental material - Communicating cancer diagnoses with children in Japan: A qualitative study of healthcare professionals’ beliefs and approaches in pediatric oncology
Supplemental material for Communicating cancer diagnoses with children in Japan: A qualitative study of healthcare professionals’ beliefs and approaches in pediatric oncology by Noyuri Yamaji, Nobuyuki Yotani, Mari Ikeda, and Takeshi Hasegawa in Palliative Care and Social Practice.
Supplemental material
Supplemental material - Communicating cancer diagnoses with children in Japan: A qualitative study of healthcare professionals’ beliefs and approaches in pediatric oncology
Supplemental material for Communicating cancer diagnoses with children in Japan: A qualitative study of healthcare professionals’ beliefs and approaches in pediatric oncology by Noyuri Yamaji, Nobuyuki Yotani, Mari Ikeda, and Takeshi Hasegawa in Palliative Care and Social Practice.
Footnotes
Acknowledgements
Ethical considerations
This study was conducted in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of Showa Medical University (approval number: 2024-071-A).
Consent to participate
All participants provided electronic informed consent prior to participation.
Author contributions
N. Yamaji designed the study, collected and interpreted the data, and collaborated on the manuscript. M. Ikeda and T. Hasegawa supervised the project and assisted with interpreting the results. N. Yotani supervised the project, recruited participants, and assisted with interpreting the results. All authors contributed to the discussion of the results and provided comments on the manuscript.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by JSPS KAKENHI [grant number: 23K19766, 24K20334] and the SGH Foundation.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Due to ethical restrictions and the terms of participant consent, the data supporting the findings of this study are not publicly available.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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