Buddhist Priests’ Traditional Activity as a De Facto Community Outreach for Older People with Various Challenges: A Mixed Methods Approach

Abstract

Little is known about monthly home visits, a traditional Japanese Buddhist custom, wherein Buddhist priests visit their parishioners’ homes every month. This study aimed to explore this custom in terms of community health care. Qualitative data were collected from 14 Buddhist priests from various areas, followed by quantitative data collection on all the temples in the Osaka parish, where 486 questionnaires were distributed and 299 were retrieved. From the interviews, the functions of the monthly home visits were categorized into the following six categories: “finding incidents”, “preventing suicides”, “caring for older people”, “grief care”, “a peaceful passing”, and “connecting people”. Ninety-one percent of Buddhist priests made monthly home visits in the Osaka parish, with a median of 30.0 times per month. The median duration of their visits was 25.0 min. Those who carried out a high number of monthly home visits had more experience in: noticing dementia or physical deterioration; being asked for advice about a serious issue; dealing with the grief of bereavement; finding someone whom they were concerned about, but being unsure to what extent to get involved; finding someone in cardiopulmonary arrest or unconsciousness; and finding someone whom they were concerned about but not knowing where to ask for help.

1. Introduction

Historically, Buddhism has supported a wide range of people’s lives in Japan (Schrimpf 2018). Since the Heian Era, which began in the 8th century when Kyoto became the imperial capital, health care in Japan has long been provided by Buddhist “priest-doctors”, where commoners found medical help in Buddhist temples. From the late 19th century, Buddhist priest doctors were challenged by both Chinese herbal medicine (kanpō) and European medical thought. After the Meiji Restoration, which aimed to establish a modern and strong nation-state, the new government developed the medical licensing system, leading to the current system created following the German model. Recently, since Buddhist temples are known to be managed mainly through the income from funeral rites and mourning services, temples are often criticized as “funeral Buddhism”; this means that Buddhist priests focus on holding rites for the deceased, and not on helping living people. In response to this criticism, according to Takahashi (2022), interfaith chaplaincy influenced by Western psychotherapy, overseas Buddhism, and traditional Japanese folk customs were established to meet the needs of the medical community as this community does not focus on religion but has high, and sometimes excessive, expectations of spiritual care. This is a framework that does not provide religious care, only spiritual care. However, only 212 interfaith chaplains exist in the country, which is far from the universal system (Society for Interfaith Chaplaincy in Japan n.d.). Taniyama and Becker (2014) suggest another possible answer to this criticism such as monthly services consisting of sutra chanting followed by chatting over tea. Chanting and chatting cannot be separated; if they create good relations between the monks and bereaved families, they can serve as a monthly time of healing for the bereaved. Although this is not explicitly stated, Japanese people with knowledge of Buddhism will know that they are referring to the “monthly home visit”.

Monthly home visits—Tsuki-Mairi (月参り) in Japanese—is a traditional Japanese Buddhist custom in which Buddhist priests visit the homes of their parishioners to perform ancestral rites and offerings for the dead, on the nearest deathday of every month (Jodo Shu, 2018). As these visits have been taken for granted in Japanese culture, they have not been the subject of much research in Japan, and there is little epidemiological literature in English on them; these have not been mentioned in pioneering works on ancestor worship in contemporary Japan (Smith 1974). Photos of a monthly home visit can be seen in Figure 1. Additionally, a video of a monthly home visit can be viewed in the Supplementary Materials (S1).

The first epidemiological studies in English on monthly home visits comprised what we had previously revealed using geographic information analysis (viz., large regional differences exist in the practice of monthly home visits, whose distribution was similar in different denominations) (Ogawa et al. 2022a), but we do not have data on when the practice began. This study is an attempt to explore this custom, which has not been the subject of academic research with scientifically valid methods, with a view to finding undiscovered solutions to contemporary social issues.

Today, the aging of modern Japanese society casts a heavy shadow. By the middle of the 21st century, it is estimated that the aging rate—calculated as the percentage of people aged over 60 years in the total population—will be 40%, and the number of people with dementia will be approximately 10% of the total population (Cabinet Office 2017). Nowadays, families are not reliable enough as social resources, given that 30% of households that include older persons are single-person households, and 30% are older married-couple households (Cabinet Office 2017). Considering that as people get older, a decrease in cognitive or physical abilities tends to occur at any time, older people are clearly at a risk of discontinuing community life against their will, as shown by empirical research. A longitudinal study conducted in Tokyo found that half of an older population with cognitive decline were unable to continue living in the community over a five-year period (Okamura et al. 2022). Therefore, there is a need for a novel outreach system to look after older people who are not being cared for or looked after. However, social resources to support older people are depleted due to the population shrinking and aging (Sano et al. 2023). Collaboration with Buddhist temples and priests, or the reallocation of existing resources that have not even been regarded as social resources by health care professionals, are a possible solution. Therefore, this study proposes the use of Buddhis priests and temples in this area (Okamura et al. 2018; Ogawa et al. 2022b).

According to a survey conducted by the Ministry of Education, Culture, Sports, Science and Technology (2016), there were more than 353,000 Buddhist priests in Japan compared with 76,000 Shinto and 32,000 Christian priests. The number of Buddhist priests in Japan is larger than that of its police officers (260,000) (National Police Agency 2021). Temples and priests are large social resources that have been overlooked in the healthcare area.

In this study, our research questions were to analyze the characteristics of monthly home visits from the perspective of health care, and not religious studies, based on the perception and behavior of priests. Furthermore, by exploring unknown data on these monthly home visits from the perspective of care, we expect to provide evidence for repositioning the existing resources for older people’s secular support system.

2. Results

2.1. Qualitative Approach

Ten Buddhist priests, who regularly carried out monthly home visits and had been selected by snowball sampling, were interviewed during 2018 without any concerns.

Table 1. Interviewees.

ID	Area	Sex	Age
N	Nagoya	M	30s
S	Osaka	M	40s
T	Osaka	M	40s
I	Osaka	M	40s
F	Osaka	M	40s
K	Osaka	M	40s
E	Akita	M	40s
A	Akita	M	60s
Y	Akita	M	50s
H	Akita	M	30s
D	Akita	M	30s
X	Akita	M	30s
M	Kanagawa	M	60s
Z	Kanagawa	M	70s

lists the basic data of the interviewees.

Concerning what the interviewees considered to be the function of the monthly home visits in the present era, the following six categories emerged: “finding incidents”, “preventing suicides”, “caring for older people”, “grief care”, “a peaceful passing”, and “connecting people”. The discourses representing each category or subcategory are listed in

Table 2. Categories, subcategories, and citations concerning what the interviewees considered to be the function of monthly home visits in the present era.

Categories	Sub Categories	Citations
Finding incidents	The function of finding hikikomoris, and being able to help them at any time.	Sometimes I meet a son who never goes out of the house (F).
		Sometimes it is difficult to ask clearly, but in the houses we visit, there may be an unmarried son, who is not working, who we think is a hikikomori (I).
		There are many single people in their 40s and 50s, and some who are hikikomoris (E).
	The function of finding people with dementia	I noticed that the person was getting the dates and timings of temple-related events wrong (S).
		I was visiting and reading sutra, when I noticed the person urinating in a washbowl behind me (T).
		I noticed (dementia symptoms) because I kept getting calls from the person in the middle of the night (F).
		I noticed (dementia symptoms) because things in the room were getting more and more confusing (K).
		Family members do not notice (older people’s dementia) because they only meet at night. I notice when non-family members enter the house on a regular basis (A).
		Once I noticed that the apples in the offering were upside down (Y).
	The function of finding people with poor physical conditions.	A woman who lives alone does not use the air conditioner no matter how hot it gets, and I watch her with concern (T).
		Noticing that the stove was unsafe because of poor maintenance, I contacted the family (A).
		I visited an old woman and found her unconscious in bed. She had wrongly taken sleeping pills (S).
Preventing suicides		I believe that the monthly visit is a factor that prevents suicide (N).
		I feel that monthly suicides are few among the people whom I visit (S).
Caring for older people	The function of physical care	The topics were mostly diseases of the elderly, about which, I became more and more familiar. The most common was knee pain (I).
	The function of dementia care (cognitive stimulation)	People with dementia put on makeup and improve their activities when they have guests. Some people with dementia have lost contact with their families even at home, but (talking with a priest) is their only contact with society (K).
		Talking with priests is a good stimulus (I).
	The function of mental health care	I kept visiting the home of a woman who could not get her room cleaned up (F).
		I notice people with “nursing depression” right away because they lose about 10 kg of weight (A).
Grief care		When I learned about grief care, I realized that it was the monthly visits that suppressed the anniversary reaction. This is because having others come and talk with them helps them to regain their daily vitality. I explain to the believers how the monthly visit was created to suppress the anniversary reaction. I do not do this for an offering (N).
		During my monthly visiting, I was asked by a person to go to Sandakan, Indonesia, to visit a friend of his, who was buried there, during World War II. Thinking that this was a chance encounter, I went there for his sake, at my own expense (S).
		The monthly visit clearly has a grief care function (K).
		When I go to a support group for the bereaved families of those who have died by suicide, I cannot talk to them one-on-one, but at the monthly visit, I can talk to them one-on-one (F).
		I started a new monthly home visit to the home of an old woman who lost her son to suicide. At first, she was depressed, so I invited her to come to the temple because people of her age would be there, and when she started coming, she recovered (D).
Supporting a peaceful passing		The older people in the houses I visit are familiar with me because they have known me since I was a little boy. (When I was visiting one house), the old lady crawled out and said, “I do not think I will see you again next time, thank you for your care”, to which I replied, “What are you talking about? I shall see you next month”, but soon she passed away. She gave me a final goodbye (Z).
		An old man I was visiting suddenly asked, “Priest, do you think there is really a paradise?” I told him, “We continue to live in people’s hearts, and the Pure Land is the same”. The next day, I heard that the man had passed away (K).
Connecting people	Preventing loneliness	The monthly visit gives people a sense of connection (N).
		The monthly visit gives people an opportunity to talk to someone (T).
		I think it is the same as providing aftercare to those who have obtained housing through homeless assistance. Some people are lonely even if they have families. We are there to create a safe place in the hearts of the residents (K).
		For the elderly who are isolated from the rest of the family, the monthly visit is the only contact they have (K).
		The monthly visit gives people an opportunity to talk to someone about something they cannot talk about with their family (A).
	Building deep relationships between people and Buddhist priests	We meet in person every month so we can build relationships and trust (T).
		What social welfare and artificial intelligence cannot do, and what remains for Buddhist priests to do, is to listen to spiritual matters (K).
		It deepens connections with the residents. Buddhist priests who do not make monthly visits tell me that our position is special, that they (are not familiar with the believers, and that they) do not go out for a beer with them (M). By going to the house, we actually know who lives there (M).
	Support in daily life	If the gas is shut off by a safety device after an earthquake, the older people will not be able to restore it. I will help them when I am called (S).
		Several times a year, I am asked to come because they do not know how to adjust the settings on their air conditioners (S).
	Community building	They are moving from their previous home to another, but they do not know how to get along with their neighbors, and they depend on us (S).
		We are in a neutral position to round out the community’s troubles. Everyone accepts when priests suggest a solution (A).

. As has been stated previously, these were incorporated into the quantitative questionnaire.

In addition, during free conversations, they expressed confidence in, and enjoyment of, their monthly home visits. In response to this, we included a scale in the questionnaire that asked about mental well-being.

At that time, there was a problem with a group of juvenile motorcycle gangs. They were gathering at a house I visited. When I was arguing with them about stopping the dangerous group of motorcycle runaways, the parents there told me that they had given up on them. So, I said to them, “You gave birth to them; so, you are responsible for them, and as parents, you should stand together against them.” Then, I told the gang “I will not even give you a funeral, if you die,” and they were surprised. After a while, the bad boys stopped doing bad things. After a long time, I went to an old lady’s funeral, and two young men in business suits came and thanked me for what I had done (i.e., stopped them, that had made them return to the right way). I was happy.

(Z)

I, myself, listen to an old lady for a long time because her stories are interesting, but some priests try to leave (the house) at 5 pm.

(K)

Many priests are unaware about the monthly visits having a function of grief care. However, I think it is amazing that they are doing it naturally, without recognizing that it is grief care. It means there is a treasure in that custom that no one knows about.

(N)

2.2. Quantitative Approach

Of the 486 questionnaires distributed, 299 (62% response rate) were retrieved (

Table 3. Comparative characteristics of Buddhist priests who carried out and did not carry out monthly home visits.

		Monthly Home Visits
		Did (n = 271)	Did Not (n = 27)	p-Value
Sex	Male	254	25	0.648
		(95%)	(93%)
	Female	14	2
		(5%)	(7%)
Age (years)	Below 60	124	11	0.686
		(47%)	(42%)
	Over 60	141	15
		(53%)	(58%)
Collaboration with public sectors	Present	98	17	0.012 *
		(37%)	(63%)
	Absent	169	8
		(63%)	(37%)
Other qualifications	Absent	107	7	0.628
		(46%)	(39%)
	Present	124	11
		(54%)	(61%)

N: number, p-value: probability value. * p < 0.05.

). There were 280 males, 16 females, 1 other, and 2 non-respondents; 156 (52%) were 60 years of age or older. Of these, 271 (91%) indicated that they carried out monthly home visits.

We compared 271 Buddhist priests who carried out monthly home visits with 27 who did not. While the two groups did not differ in terms of age, gender, or other qualifications they possessed, the priests who did not make monthly home visits were more likely to interact with the public sector, as shown in Table 3.

Among the respondents who answered regarding conducting monthly home visits, 246 filled in the number of their monthly home visits. The average number of monthly visits for each priest was 42.3 (±39.4), and the median was 30.0 (Figure 2a). The average duration of visits was 26.1 (±10.5) minutes, with a median of 25.0 min (Figure 2b), and the longest stay was 53.6 (±26.4) minutes, with a median of 60 min (Figure 2c). As for the longest stay, the number of respondents decreased significantly over 60 min (92% of the respondents stayed less than 60 min), suggesting that the respondents may have a tendency to try to finish once they reached the 60-min time limit.

The proportion of visits to older persons was 78.8 (±29.1)%, with a median of 88% (Figure 3a). The proportion of homes visited where the older person lived alone was 25.8 (±24.1)%, with a median of 20.0% (Figure 3b).

While 90% of the respondents reported that the number of monthly home visits had decreased compared with 10 years ago, 89% expected it to decrease in the future. Half of the respondents answered that they did not know when their monthly home visits began, whereas among those who did know, more than half answered that it was between the establishment of the modern nation of Japan (1868) and the end of World War II (1945) (

Table 4. The beginning of monthly home visits.

Edo Period (Tokugawa Shogunate) (1603–1848)	21	9%
Pre-World War II of Modern Japan (1868–1945)	70	29%
Post-World War II of Modern Japan (1945–)	29	12%
Did not know	118	50%

).

The Buddhist priests’ recognition and practices relating to monthly home visits are presented in

Table 5. Buddhist priests’ recognition and practice concerning monthly home visits.

	All	Usual (–59)	High (60–)
	N = 246	N = 184	N = 62	p Value
Items concerning priests’ recognition
An opportunity to deepen trust with parishioners.	234 (86%)	172 (94%)	57 (92%)	0.772
An opportunity for older persons living alone to talk with a Buddhist priest.	209 (77%)	153 (83%)	52 (84%)	1.000
An opportunity for Buddhist priests to watch over older persons and notice any unusual changes in them.	144 (53%)	103 (56%)	37 (60%)	0.658
An opportunity for believers to consult with Buddhist priests about problems in their daily lives.	108 (40%)	73 (40%)	31 (50%)	0.181
An opportunity for grief care.	92 (34%)	65 (35%)	24 (39%)	0.649
An opportunity for congregation members to consult with Buddhist priests about mental and physical issues.	90 (33%)	61 (33%)	28 (45%)	0.095
Items concerning suicide prevention
Being involved in activities related to suicide prevention.	3 (1%)	1 (1%)	2 (3%)	0.157
Items concerning priests’ practice
Experienced listening to people’s recent situation.	213 (79%)	154 (84%)	56 (92%)	0.141
Experienced consultations regarding Buddhist matters.	201 (74%)	145 (79%)	54 (89%)	0.129
Experienced noticing dementia or physical deterioration.	182 (67%)	127 (69%)	54 (87%)	0.005 **
Experienced listening to people with physical ailments.	177 (66%)	129 (70%)	45 (74%)	0.629
Experienced listening to memories of the deceased.	117 (43%)	83 (45%)	31 (51%)	0.462
Experienced being asked for advice about a serious issue.	115 (42%)	72 (39%)	41 (66%)	>0.001 ***
Experienced listening to the problems of family relationships.	95 (35%)	65 (35%)	29 (48%)	0.097 †
Experienced being asked to support daily life.	80 (30%)	53 (29%)	27 (44%)	0.041 *
Experienced listening to people with mental health problems.	69 (26%)	48 (26%)	20 (33%)	0.325
Experienced dealing with the grief of bereavement.	66 (24%)	42 (23%)	23 (38%)	0.029 *
Experienced finding someone whom they were concerned about, but being unsure to what extent to get involved.	58 (21%)	28 (15%)	29 (47%)	>0.001 ***
Experienced listening to financial problems	35 (13%)	22 (12%)	13 (21%)	0.090 †
Experienced finding someone they were concerned about, and contacting public authorities, etc.	24 (9%)	13 (7%)	11 (18%)	0.024 *
Experienced finding someone in cardiopulmonary arrest or unconsciousness.	15 (6%)	7 (4%)	8 (13%)	0.026 *
Experienced finding someone whom they were concerned about, but not knowing where to ask for help.	13 (5%)	4 (2%)	9 (15%)	>0.001 ***
Items concerning psycho-social characteristics
Having good mental well-being.	187 (73%)	127 (73%)	44 (75%)	1.00
Having general trust.	236 (90%)	159 (90%)	58 (97%)	0.114
Having general trust in this community.	201 (79%)	136 (79%)	48 (80%)	1.00
Having attachment to the community.	239 (92%)	160 (91%)	60 (98%)	0.080 †
Basic items
Age (>60)	141 (53%)	96 (53%)	30 (51%)	0.881
Sex (male)	254 (95%)	11 (6%)	2 (3%)	0.527
Interacting with public sectors	98 (37%)	115 (63%)	37 (61%)	0.763
Having other qualifications	124 (54%)	85 (54%)	28 (54%)	1.00

N: number, p-value: probability value. * p < 0.05, ** p < 0.01, *** p < 0.001, † p < 0.01.

. Concerning their recognition, in order from the most common, comprised opportunities to deepen trust with parishioners (86%), for older persons living alone to talk with a Buddhist priest (77%), and for Buddhist priests to watch over older persons and notice any unusual changes in them (53%). Concerning practice, in order from most common, the priests reported that they had experienced listening to people’s recent situations (79%), consultations regarding Buddhist matters (74%), and noticing dementia or physical deterioration (67%). When priests with a high number of monthly home visits were compared with the usual priests, there was no difference in recognition, but they had more experience in noticing dementia or physical deterioration; being asked for advice about a serious issue and support in daily life; dealing with the grief of bereavement; finding someone whom they were concerned about but being unsure as to what extent to get involved; finding someone in cardiopulmonary arrest or unconsciousness; and finding someone whom they were concerned about, but not knowing where to ask for help. Furthermore, they tended to have more experience in listening to family relationship and financial problems. They also had a tendency to have more attachment to the community.

3. Discussion

The fact that despite monthly home visits being practiced in so many temples but has neither been a subject of academic research, nor is it available in the English literature, is in itself, an interesting phenomenon. This may be because it is perceived as too common, to the extent that no researcher has been willing to investigate it, or perhaps do not see the value in it because it is an old practice. Regarding collaborating with religious workers in the care of older people in the community, there have been reports from a spiritual care perspective. According to Ilmi et al. (2024), these are spiritual interventions that use mindfulness, singing, etc., and not those used in this study; hence, the idea that traditions that have been practiced unchanged for a long time, in their original form, are conducive to community care. In this regard, to the best of our knowledge, this study adopted a direction that has not been previously studied.

In terms of recognition, there was no difference between priests who did 60 and more visits, and those who did less than 60. However, concerning the practice, there were differences. More monthly home visits were related to having more experience of facing the crises and sufferings of older people living in the community. Simultaneously, the priests were increasing their opportunities to be relied upon by older people and their attachment to the community. These experiences increase their competence as community resources. While this study also revealed that the tradition of monthly home visits is gradually weakening, unexpectedly high recognition from the medical and care arenas will lead to a reassessment of its value in the Buddhist community, which in turn, could lead to an increase in its potential for community care.

Historically, all citizens were registered at temples through their family during the Edo period. This system clearly has its foundation in old familism and the Danka system, whose influence is still significant, and population coverage large. Considering that the seven traditional Buddhist denominations in Japan were harmonious with the modern nation state, apparently violent and radical ideologies come from a very new religion, and not from traditional Buddhism. Hence, it is possible for these denominations to work with the secular state and move toward age-friendly communities. Monthly home visits could become a way of looking after older people who are suffering from loneliness in modern communities.1

This study described monthly home visits from an epidemiological and medical perspective. However, in terms of behavior, this does not mean that religious practice is legitimatized by medical evidence. Schrimpf (2018), citing Rothstein (2004), accurately and critically discussed the current situation in Japan as “no religion of the modern world will successfully be able to claim authority without some kind of scientific legitimization”. Buddhist priests who perform monthly home visits do not see themselves as practicing medicine or trying to compete with it; neither do the residents see it as such. We report that monthly home visits have a multifaceted value; it is practical even when assessed through the methodology of medicine. We hope that this study will provide an opportunity for contemporary Japanese medicine, which is facing a variety of challenges, such as an increased number of people with dementia, frailty, multi-comorbidity, and difficulty with medical decision-making, to recognize externalities and encourage communication with the religious community.

This study also raises an issue with the Japanese Buddhist community. As discussed in the Introduction section, the Japanese Buddhist community has been subjected to the so-called “funeral Buddhism” criticism. In response, “original” Buddhism was complementary, and alternative medicine in the modern sense of the term obscures the reality of religious practice. Benedict (2018) conducted deeply engaged participation research, reporting that the essence of Buddhist hospice (Vihāra) lies not only in religious rituals, but also in treating the patient as a person. This echoes the monthly home visit, which is also an act of caring for people, with priests conducting outreach for those who cannot afford to go to the temples.

As previously mentioned, after the German medical system was introduced in the Meiji Era, only biological medicine was considered medical care. This led to criticism of “Western medicine” and the emergence of a notion that “Eastern medicine” is holistic and preferable medicine, which is in fact an “invented tradition”. Unlike such claims, this paper argues that the monthly home visit is purely a religious act that is linked to people’s well-being and safety, and that respect should be paid to those involved in it. In other words, monthly home visits tell us what biological medicine, which Japanese people regard as Western medicine, is missing.

Contemporary Japan has several schemes, wherein, someone makes regular visits to an older person’s home to detect changes early and reduce risks. One scheme is a business practice by Japan Post, in which, once a month, a postal worker visits and writes a report to relatives. The other is a long-term care insurance scheme, in which, on certification, a helper regularly provides physical care relating to meals, toileting and bathing, and assistance with daily living, such as cleaning, laundry, shopping, and cooking, at their own home. To compare these secular services and monthly home visits, we had no scientific data; accordingly, we are not arguing that monthly home visits are superior to existing services but suggest that it can be one option for community residents. Grief care and peaceful passing, which were identified in this study, are unique functions of the monthly home visits by Buddhist priests, who have a wealth of experience in bereavement and death, and might be difficult to replace with other visiting services. Although we could not find data concerning community residents, some data suggest that 71% of care workers in geriatric institutions wanted support from outside by Buddhist priests to manage the anxiety and distress of the residents (Okamura et al. 2018). This is collateral evidence that monthly home visits are easily accepted in contemporary society. However, to gain data concerning the benefit and challenges of the monthly home visit is the mission of future research.

The policy recommendations from this study are as follows. First, we propose officially recognizing through official government texts, etc., the clinical collaborations between community comprehensive support centers—key players created by the government in the community comprehensive care system (Japan International Cooperation Agency (JICA) 2022)—and Buddhist temples, and doing this without financial collaboration. This proposal can be immediately implemented and quickly accomplished, given that, one of the tasks of a community comprehensive care center is community networking. Second, in recent years, some Buddhist priests living in temples, but working in the secular system as caregivers, have emerged as public health nurses, and sometimes medical doctors. It is only natural for the secular state to pay them for their work through the insurance system. They could provide momentum to strengthen community care in Japan, but as nothing is known about this either, it is a subject for future research.

A limitation of this study is that its quantitative data was limited to the Osaka parish, and as the rate of implementation of the monthly home visit custom varies widely by region (Ogawa et al. 2022a), all of the categories that emerged in the qualitative approach in the questionnaires could not be included for realistic reasons. For example, questions such as, “Have you ever experienced finding a person who was committing suicide or had committed a suicide?” could not be included because it might be too provocative. Finally, this study was based on the authentic history of Japanese Buddhism and may be from the male perspective. Regarding gender differences, the OECD report (Ferrant et al. 2014) indicates that unpaid care work is still predominantly performed by females. On the other hand, the WHO report (Boniol et al. 2019) indicates that the percentage of females in the healthcare profession is increasing. Given that our focus is on the care activities of Buddhist priests, it can be argued that more females should enter this field. Further research focusing on gender differences, especially on the interaction between the female priest and male/female laity, is needed.

4. Materials and Methods

4.1. Methodology

This study used a mixed methods approach and adopted an exploratory sequential design to explore diverse perspectives and uncover relationships that existed between the intricate layers of our multifaceted research questions, as were stated above (i.e., questions including what and how) (Creswell and Clark 2007; Shorten and Smith 2017; Tashakkori and Creswell 2007). To obtain an overall picture of the issue, first, qualitative data collection and analysis were conducted, and using this as a basis, thereafter, quantitative data collection and analysis were conducted. An overview of this study’s methodology is described in

Table 6. An overview of this study.

Approach	Qualitative Approach	Quantitative Approach
Methods	Interview survey	Questionnaire survey
Questions	What are monthly home visits?	How they affect the Buddhist priests and our community.
Schema	Diverse areas Critical assessments by the interdisciplinary team. including healthcare professionals	One area

to enable readers to understand it in the specific context.

The study was not intended to benefit any particular religion or denomination but rather to explore how existing resources are autonomously being transformed in response to an aging secular society, and whether collaborations with existing resources, such as Buddhist temples and priests, can be incorporated into a national dementia strategy.

4.2. Qualitative Approach

4.2.1. Participants

Experience has shown that the activities of Buddhist priests have remained unchanged over the ages, but due to their activities not being computerized, it was expected, that information would not be found in a desk search or in the gray literature. As there was no reason to keep the Buddhist priests’ activities secret, and given that, they had always responded openly to our questions, we decided that the best way to grasp the actual situation would be by asking the priests who actually conduct the activities. Fourteen Buddhist priests—five from Osaka, six from Akita (northeast area), two from Kanagawa (south of Tokyo), and one from Nagoya—who regularly conducted monthly home visits, were selected by snowball sampling.

4.2.2. Methods

This simple interview guide included the number of visits per day; descriptions of the houses visited and behavior during the visits; subjects of talk; whether or not they had met people with challenges such as dementia, withdrawal symptoms, etc.; and any impressive episodes they wished to talk about. The contents of the interviews were immediately shared with the team.

4.2.3. Data

The interviews were audio recorded and verbally transcribed. The verbatim transcripts were sent to the participants for approval of the contents.

4.2.4. Analysis

A qualitative descriptive approach (Neergaard et al. 2009) was adopted, as it is useful in exploratory studies in which little is known about the topic in question. What interviewees considered to be the function of the monthly home visits in the present era was analyzed. Text fragments were coded using MAXQDQ 2022^®. Constant comparisons were conducted.

4.3. Quantitative Approach

4.3.1. Participants

Priests attached to all the 486 temples in Osaka parish, belonging to one of the seven main denominations of Japanese Buddhism.

4.3.2. Methods

The questionnaires were mailed to the participants and retrieved. This study was conducted from 1 to 30 October 2022.

4.3.3. Data

In addition to basic characteristics (sex and age), the questionnaire inquired whether the priests were involved in any activities (i.e., other than being Buddhist priests), and whether they collaborated with the public sector. The reason for including this question was because of the interest in the Buddhist priests’ social engagement.

The priests were asked if they conducted monthly home visits, and if they answered that they did not, the survey was ended then and there. Those who answered that they did visit were asked about the number of monthly home visits by their temple, and the number of its priests who were engaged in them. Additionally, they were asked about the number of monthly visits to houses with older people, the number of older people who lived alone, average duration of visits, and maximum duration of a visit. The questionnaire also included questions on how long they had been following this custom, whether it was currently decreasing, and whether they thought it would decrease in the future.

Based on the qualitative data, the priests were asked about their perceptions and practices related to monthly home visits. The research team discussed the qualitative data and formulated questions on the themes that emerged from the qualitative analysis. The questions are shown in

Table 7. Questions about the priests’ perceptions and practices concerning monthly home visits in the questionnaire.

	Questions to Ask about Recognition: “Do You Think Monthly Home Visits Are...?”	Questions to Ask about Practice: “During the Monthly Home Visits, Have You Experienced...?”
Finding incidents	...is an opportunity for Buddhist priests to watch over older persons, and notice any unusual changes in them.	…experienced noticing dementia or physical deterioration.
		…experienced finding someone they were concerned about, and contacting public authorities, etc.
		…experienced finding someone in cardiopulmonary arrest or unconsciousness.
Caring for older people	...is an opportunity for congregation members to consult with Buddhist priests about mental and physical issues.	…experienced listening to people with physical ailments.
		…experienced listening to people with mental health problems.
Grief care	…is an opportunity for grief care.	…experienced talking about the deceased.
		…experienced dealing with the grief of bereavement.
Preventing loneliness	…is an opportunity for older persons living alone to talk with a Buddhist priest.	…experienced listening to people’s recent situation.
		…experienced being asked for advice about a serious issue.
Daily life support	…is an opportunity for believers to consult Buddhist priests about problems in their daily lives.	…experienced being asked for support in daily life.
Others	Are you involved in activities related to suicide prevention?	…experienced consultations regarding Buddhist matters.
		…experienced listening to family relationship problems.
		…experienced listening to financial problems.
		…experienced finding someone whom they were concerned about, but being unsure to what extent to get involved.

.

Additionally, they were asked about trust in general, general trust in the community, and attachment to the community as well as about mental well-being using the Japanese version of the World Health Organization-Five Well-Being Index (Awata et al. 2007), in which a score of 12 or less indicates poor mental well-being.

4.3.4. Analysis

Buddhist priests who carried out monthly home visits and those who did not were compared with respect to age, gender, whether or not they had collaborations with the government, and whether or not they had other qualifications, using the χ-square test, as this study was interested in the differences between priests who performed many monthly home visits, and those who did not. The number of monthly home visits for each priest (n) was calculated using the formula below.

n = (total number of visits)/(number of priests involved)

As the 75 percentile was 60, priests who made 60 and over monthly visits and those who made less visits, were similarly compared using the χ-square test. A p-value below 0.05 was regarded as statistically significant. Furthermore, considering that this was an exploratory research study, a p-value below 0.01 was regarded as a tendency.

5. Conclusions

This study described monthly home visits from an epidemiological and medical perspective. The monthly home visit is purely a religious act that is linked to people’s well-being and safety, and where respect should be paid to those involved in it. Considering that the social resources to support older people are being depleted because of population shrinking and aging, collaboration with Buddhist resources is a possible solution for healthcare professionals. However, at this time, there is very little available data on traditional Buddhist resources to which health services researchers can refer, so the findings from this study will provide a basis for future dialogue.