Widowers' Grief Experiences and Perceptions of Prolonged Grief Disorder: A Qualitative Study on Male Mental Health in Taiwan.

Widowers’ Grief Experiences and Perceptions of Prolonged Grief Disorder: A Qualitative Study on Male Mental Health in Taiwan - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Am J Mens Health . 2026 May 29;20(3):15579883261453352. doi: 10.1177/15579883261453352 Widowers’ Grief Experiences and Perceptions of Prolonged Grief Disorder: A Qualitative Study on Male Mental Health in Taiwan Hsiang-Wan Tseng 1 , Shwu-Hua Lee 2, 3 , Kuo-Chen Liao 3, 4 , Ching-Yen Chen 3, 5 , Hsiu-Lan Lee 1, 6 , Yun-Fang Tsai 1, 5, 7, ✉ Author information Article notes Copyright and License information 1 School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Taiwan 2 Department of Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan 3 School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan 4 Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan 5 Department of Psychiatry, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan 6 Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan 7 Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan ✉ Yun-Fang Tsai, School of Nursing, College of Medicine, Chang Gung University, 259 Wen-Hwa 1st Road, Taoyuan, Taiwan 333. Email: yftsai@mail.cgu.edu.tw Received 2026 Feb 26; Revised 2026 Apr 29; Accepted 2026 May 7; Collection date 2026 May-Jun. © The Author(s) 2026 This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( https://creativecommons.org/licenses/by-nc/4.0/ ) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage ). PMC Copyright notice PMCID: PMC13222447  PMID: 42216469 Abstract The death of a spouse is a major life stressor for men, yet cultural and gender norms shape how grief is experienced and expressed. This qualitative study explored widowers’ grief experiences and perceptions of prolonged grief disorder (PGD) in Taiwan, focusing on implications for male mental health. Eighteen widowers were recruited from five outpatient clinics and interviewed using a semi-structured guide, and data were analyzed using a phenomenological approach based on Giorgi’s method. Four themes emerged: grief subordinated to paternal and familial responsibilities, with men prioritizing child-rearing and household duties over emotional processing; emotional restraint and internalized suffering, reflecting loneliness and rationalized acceptance of loss; functional impairment as the threshold for disorder, with grief seen as problematic primarily when daily functioning was disrupted; and help-seeking framed as pragmatic responsibility, with medical intervention pursued to restore role performance or fulfill moral duties to the deceased. An outlier case highlighted variability in marital intimacy and grief intensity. Participants’ perceptions of PGD were guided by functional impact rather than grief duration alone, and masculine and cultural norms shaped coping and help-seeking. These findings provide insights into male grief in an East Asian context and highlight the importance of culturally sensitive interventions that support role continuity, adaptive coping, and awareness of male mental health. Keywords: bereavement, widowers, grief, prolonged grief disorder, male mental health Introduction The death of a spouse is one of the most stressful life events and can significantly impact psychological and physical health ( Stroebe et al., 2007 ; Szuhany et al., 2021 ). Widowers may be particularly vulnerable in this context, as cultural and gender expectations often emphasize emotional restraint, self-reliance, and family responsibility ( Siegel & Kuykendall, 1990 ; Yu et al., 2021 ). Men have been shown to exhibit greater increases in depressive symptoms following bereavement ( Förster et al., 2019 ), as well as heightened risks of mortality and dementia ( Kawaguchi et al., 2026 ). In addition, bereavement is associated with more substantial psychosocial disruption among men ( Yoon et al., 2022 ), consistent with earlier findings of elevated distress in this group ( Stroebe & Stroebe, 1983 ). Together, these findings point to a pattern of heightened vulnerability among widowers, which may be attributable to masculine norms shaping emotional expression, role adjustment, and engagement with support resources ( Kersting et al., 2011 ). In Chinese cultural contexts, men are traditionally expected to serve as providers and maintain family stability, which may limit opportunities for emotional expression ( Zhou et al., 2023 ). Taiwanese bereavement practices, rooted in Confucian values of filial piety, mutual dependence, and interpersonal harmony, further encourage suppression of negative emotions to maintain dignity and avoid burdening others ( Liang et al., 2024 ). Traditional mourning rituals—including periodic memorial ceremonies in the first weeks after death, the 100th-day observance, and annual death anniversaries—emphasize continuity of family roles and respect for the deceased ( Lee et al., 2015 ). These practices not only structure culturally normative timelines of grieving but also shape expectations regarding when and how grief should be expressed, thereby influencing the perceived boundary between normal grief and clinically significant grief responses. For example, the anniversary ritual involving the collective placement of memorial tablets in a columbarium symbolically marks a transition toward acceptance and closure. In this sense, mourning rituals may simultaneously regulate grief expression at a social level and function as culturally sanctioned mechanisms that facilitate adaptation. Consequently, they may both reinforce expectations against prolonged overt grieving and serve as culturally embedded resources for adjustment ( Le et al., 2025 ). These cultural norms and practices therefore play an important role in shaping how widowers navigate grief, as well as how deviations from these expectations may be interpreted in relation to clinical constructs such as prolonged grief disorder (PGD). PGD, recently formalized in Diagnostic and statistical manual of mental disorders (5th ed., text rev.) ( DSM -5-TR), is characterized by persistent, intense grief accompanied by functional impairment ( American Psychiatric Association [APA], 2022 ; World Health Organization [WHO], 2020 ). While PGD is increasingly recognized clinically, few studies have explored how men perceive the boundary between normal grief and disorder, or how masculine expectations shape help-seeking behaviors ( Lundorff et al., 2017 ; Maccallum et al., 2017 ; Nielsen et al., 2019 ). Understanding these perceptions is critical for developing culturally and gender-sensitive interventions that support men’s mental health. However, existing theories of masculinity and grief do not fully capture the experiences of widowed men. Masculinity frameworks emphasize gendered expectations such as emotional restraint and responsibility ( Connell, 2005 ; Gough, 2018 ), while dominant grief models—largely developed in Western contexts—prioritize individual emotional processing ( Hilberdink et al., 2023 ). Together, these perspectives may overlook culturally embedded and role-oriented expressions of grief. To address this limitation, this study adopts a culturally informed, role-oriented lens to examine widowers’ experiences of grief and their perceptions of grief as a mental health disorder, with particular attention to masculine role expectations, functional responsibilities, and help-seeking behaviors. The resulting conceptual framework is presented in the Results section. Methods Design and Theoretical Orientation This qualitative study employed a phenomenological approach ( Creswell & Poth, 2023 ) to explore widowers’ lived experiences of spousal loss and their interpretations of PGD. The study adopted a gender-sensitive perspective grounded in masculinity theories ( Connell, 2005 ; Gough, 2018 ), which directed attention to how masculine role expectations—such as emotional restraint, responsibility, and functional competence—shape men’s experiences of distress, their interpretations of psychological symptoms, and their definitions of the boundary between normal grief and mental disorder. This perspective also guided the analytic focus on how participants constructed meanings of grief within cultural expectations of masculinity, as well as within a clinical context where bereavement may intersect with medical interpretation. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) ( Tong et al., 2007 ). Sample and Setting Participants were purposively recruited from geriatric and internal medicine outpatient clinics at two medical centers, two regional hospitals, and one district hospital in northern Taiwan between November 2023 and August 2024. Physicians referred eligible widowers who had experienced the loss of a spouse. Recruiting participants from health care settings enabled exploration of grief experiences within a medical context, where bereavement may be discussed alongside physical health concerns, and where prolonged grief may be considered for clinical assessment. The inclusion criteria were (a) age ≥ 18 years old; (b) experienced the loss of a spouse at least 3 months before enrollment; and (c) ability to communicate verbally and adequate cognitive functioning as confirmed by the JOMAC (Judgement, Orientation, Memory, Abstract, and Calculation) assessment. Participants with evident cognitive impairment or inability to provide informed consent were not included. The 3-month interval was selected in consideration of Chinese cultural mourning practices, including the 100-day commemorative ritual, which may influence the bereavement process. Data Collection Data were collected through individual, face-to-face, in-depth interviews guided by a semi-structured interview guide ( Table 1 ) developed by the research team. The guide explored experiences of spousal loss, coping strategies, role changes, and perceptions of prolonged grief as a mental health condition. Content validity was assessed by an expert panel of 10 professionals in bereavement and mental health care, including four physicians, four clinical nurses, a clinical psychologist, and a social worker, with minor revisions made based on their feedback. In addition, pilot interviews were conducted with two eligible participants, and these interviews were excluded from the final analysis. Pilot feedback indicated that the interview guide was clear and feasible; therefore, no substantive changes were required before formal data collection. Table 1. Semi-Structured Interview Guide. 1. Relationship and Role Context Can you describe your relationship with your wife before she passed away? What roles did each of you play in the family? How would you describe your daily life together? 2. Impact of Loss and Life Adjustment How has your life changed since her passing? What responsibilities have increased or shifted? How have you managed daily routines and family obligations? 3. Emotional Experience and Coping How would you describe your feelings after her death? How do you usually deal with feelings of sadness or loneliness? Who do you turn to for support, if anyone? Do you feel comfortable sharing your grief with others? Why or why not? 4. Perceptions of Prolonged Grief and Mental Health What does “prolonged grief” mean to you? At what point, if any, do you think grief becomes a mental health problem? What signs would indicate that someone should seek professional help? How do you feel about seeing a doctor or mental health professional for grief? Open in a new tab The interviews were conducted in Mandarin Chinese by a trained female research assistant (RA), a registered nurse with a bachelor’s degree and prior qualitative interviewing experience. She had no prior relationship with participants. Interviews were conducted in private rooms within hospital settings and lasted between 6 and 58 minutes. All interviews were audio-recorded with participants’ consent. Each participant took part in a single individual interview, and no follow-up interviews were conducted. Given the potential influence of gender dynamics on participants’ willingness to disclose emotional experiences, the RA maintained reflexive field notes documenting participants’ emotional expressions, hesitations, and interactional dynamics during interviews. The research team also engaged in ongoing reflexive discussions regarding how the gender of the female RAs and the male widowed participants may have shaped the interview process and data generation. Throughout the interviews, the assistants adopted a respectful and non-judgmental stance to help minimize potential power imbalances and facilitate open narrative sharing. Following each interview, demographic information was collected, including age, education, religious beliefs, living status, number of children, caregiving history, cause of death, and time since loss. Data collection continued until thematic saturation was reached. A final sample of 18 widowers was included in the study. Saturation was defined as the point at which no new conceptual insights emerged during consecutive interviews and was monitored through ongoing iterative analysis conducted along with data collection. Data Analysis All interviews were transcribed verbatim within 48 hours of completion. Data analysis followed an inductive coding approach, without a pre-specified coding framework. The analysis was conducted using a phenomenological approach based on Giorgi’s method ( Giorgi, 2009 ), which emphasizes identifying meaning units, transforming them into psychologically relevant codes, and synthesizing the overall structure of participants’ lived experiences. The first author and research team engaged in iterative readings of all transcripts to achieve immersion and ensure familiarity with the data. Meaning units relevant to grief experiences, masculine role expectations, functional responsibilities, and perceptions of grief as a mental disorder were identified and coded. Codes were then compared across participants and clustered into broader themes through team discussions. Particular analytic attention was given to how participants framed emotional expression, family and parental responsibility, help-seeking behaviors, and functional impairment. Discrepancies in interpretation were resolved through consensus within the research team. Demographic data were analyzed using descriptive statistics (frequencies, percentages, means, and standard deviations) with SPSS version 23.0. Rigor Trustworthiness was ensured using strategies described by Lincoln and Guba, including prolonged engagement with transcripts, peer debriefing, member checking, and maintaining an audit trail ( Lincoln & Guba, 1985 ). Peer debriefing involved regular meetings with qualitative research experts to review coding decisions and thematic development. Member checking was conducted with two participants who reviewed transcripts and preliminary interpretations for accuracy and resonance. Reflexivity was maintained through analytic memos documenting methodological decisions and researchers’ assumptions, particularly regarding gender norms and men’s emotional expression. This process enhanced confirmability and transparency in interpretation. Ethical Considerations The study was approved by the institutional review board of a medical foundation in Taiwan and conducted in accordance with the Helsinki Declaration. Eligible participants received explanations of the study and provided written informed consent. Participants were informed of their right to withdraw at any time without consequences. A small token of appreciation (approximately USD $6) was provided after the interview. Findings A total of 22 individuals were approached, of whom four declined to participate due to time constraints. The remaining 18 men participated in this study, with a mean age of 66.7 years ( SD = 7.9, range = 46–77). The majority of participants were primary school graduates ( n = 11), indicating completion of elementary-level education (approximately 6 years of formal schooling in Taiwan). Most participants lived with a child ( n = 14), had cohabited with the deceased prior to death ( n = 18), and had been the primary caregiver of the deceased ( n = 16). The average time since the deceased’s passing at the time of the interview was 22.9 months ( SD = 17.9, range = 3–60 months). For details, see Table 2 . Table 2. Participants’ Characteristics ( N = 18). Characteristic n Mean ( SD ) Age, years (range: 46–77) 66.7 (7.9) Education level Primary school 11 Junior high 4 ≥Senior high 3 Religious belief Buddhism 4 Taoism 8 Belief in God, but no specific religion 5 None 1 Marital status Widowed 18 Living status Live alone 3 With child 14 With partner and child 1 Number of children (range: 2–5) 3.2 (0.9) Did you reside with the deceased prior to their death? Yes 18 Were you the primary caregiver of the deceased? Yes 16 No 2 The cause of death of the deceased Nature 16 Accident 2 Interview timeline since the deceased’s passing (range: 3–60 months) 22.9 (17.9) Open in a new tab Continuous variables are presented by mean and standard deviation, with categorical variables presented by frequency. Our analysis revealed four overarching themes that illustrate how widowers negotiated grief: (a) grief subordinated to paternal and familial responsibility; (b) emotional restraint and internalized suffering; (c) functional impairment as the threshold for disorder; and (d) help-seeking framed as pragmatic responsibility rather than vulnerability. Together, these themes form the conceptual framework of widowers’ grief experiences, indicating that participants described grief not only in emotional terms but also in relation to functional capacity, family obligations, and perceptions of mental health (see Figure 1 ). Figure 1. Open in a new tab Conceptual framework of widowers’ grief experiences in Taiwan. Theme 1: Grief Subordinated to Paternal and Familial Responsibility Widowers consistently described placing family responsibilities above personal emotional needs. Grief was often managed privately to ensure continuity of parental and household roles. Prioritizing Child-Rearing Over Emotional Expression Participants who lost their wives at a younger age emphasized their responsibility to care for their children, often suppressing their own grief to maintain stability. During the time she passed, I was emotionally drained and had to handle both work and family matters. All I could do was quickly arrange the funeral and try to return to my normal life as soon as possible, as I still had a child to care for. (C12) With two children to care for, I have no choice but to move forward. (C14) Grief was often described as something that needed to be set aside or controlled to continue fulfilling parental responsibilities. Maintaining Family Stability Through Endurance Participants described managing financial affairs, funeral arrangements, and daily routines despite intense sorrow. When she passed away, I was devastated, but I had to push through the pain to handle her funeral arrangements. (C5) Participants frequently referred to enduring or “pushing through” their grief while maintaining family stability. Theme 2: Emotional Restraint and Internalized Suffering Although participants described profound sadness, loneliness, and longing, overt emotional disclosure was limited. Grief was frequently internalized and endured rather than openly expressed. Loneliness Without Emotional Collapse Men living alone after their spouse’s death emphasized solitude but rarely described loss of control. After my wife passed away, I’m the only one left at home. I feel very lonely, and it’s hard to get used to. (C15) Participants often described focusing on adapting to their new living situation. Acceptance Framed Through Rationalization Participants who had cared for chronically ill spouses often framed death as relief from suffering. When I thought about the immense pain she endured, I knew I had to let her go. (C3) Acceptance was often described in terms of understanding or reasoning about the situation rather than expressing emotional resolution. Theme 3: Functional Impairment as the Threshold for Disorder Participants did not describe prolonged grief solely by duration or intensity of sadness. Instead, many referred to the impact of grief on daily functioning when discussing whether it became problematic. Grief Becomes Problematic When It Disrupts Daily Life Participants who supported the concept of PGD often described impairment in daily functioning. If you’re still feeling sad after more than a year and it affects your daily life, it should be a sign that something is wrong. (C11) Being constantly trapped in grief can affect normal daily life. (C12) Persistent sadness alone was often described as less concerning than difficulties in maintaining everyday activities. Duration as Secondary to Role Performance Some participants described that maintaining daily responsibilities was more important than how long grief lasted. Life has to go on; otherwise, what about the other family members and children? (C1) Time was mentioned as relevant, but continued role performance was frequently referred to as an indicator of coping. Theme 4: Help-Seeking Framed as Pragmatic Responsibility Rather Than Vulnerability Participants described seeking professional support in relation to practical needs rather than emotional expression. Medical Assistance as Restoration of Function If you can’t move on and it starts affecting your daily life, it’s important to see a doctor. (C14) Participants often referred to seeking medical help when difficulties began to interfere with daily functioning or responsibilities. Moral Responsibility Toward the Deceased Some participants linked their coping and recovery to a sense of moral responsibility toward the deceased. If you keep thinking about her, it’s not good for you, and you constantly make her worry. How can she leave in peace? (C5) Participants described the need to regulate their grief to allow the deceased to “leave in peace.” Outlier Case One participant reported no significant emotional attachment to his spouse and experienced minimal distress following her death. He delegated funeral responsibilities to his son and described no change in daily life. This case highlights variability in marital intimacy and suggests that grief responses are shaped by relational context. Discussion This study examined the grief experiences of Chinese widowers and their perceptions of PGD, highlighting the role of masculinity, family roles, and cultural norms in shaping bereavement. The findings are organized in relation to the conceptual framework presented in Figure 1 , which comprises four interrelated dimensions: functional responsibility, emotional regulation, relational obligation, and perceptions of mental health. Together, these dimensions structure how widowers interpret, manage, and evaluate their grief within socially and culturally defined expectations. Participants consistently described prioritizing family responsibilities over personal emotional needs, maintaining family stability and financial responsibility while suppressing grief. This suggests that grief was not primarily constructed as a space for individual emotional processing, but as a condition regulated through paternal and familial obligations. These patterns appear to be embedded within culturally informed expectations and gendered role norms rather than reflecting individual coping strategies alone. From the perspective of masculinity theories ( Connell, 2005 ; Gough, 2018 ), such emphasis on responsibility and emotional restraint aligns with socially constructed expectations of men as providers and family stabilizers. In the Chinese cultural context, grief is therefore shaped not only by bereavement itself but also by expectations of role continuity, emotional control, and relational duty, including ongoing bonds with the deceased. In contrast, Western grief models tend to emphasize emotional expression and individual meaning-making processes ( Hilberdink et al., 2023 ; Zhou et al., 2023 ). Our findings suggest that Taiwanese widowers’ grief responses are more relationally and functionally oriented, rather than primarily expressive. This highlights cultural variability in bereavement experiences and cautions against assuming the universality of Western grief frameworks. These findings are consistent with prior research indicating that young widowers experience significant stress in balancing parenting and employment responsibilities while grieving ( Barros-Lane et al., 2026 ; Donohue et al., 2025 ; Garcini et al., 2021 ). In the context of Taiwan’s increasingly nuclear family structure ( Directorate General of Budget, Accounting and Statistics, Executive Yuan, 2025 ), reduced access to extended family support may further intensify this burden. Thus, culturally sensitive interventions should not only encourage emotional processing but also support men in managing role responsibilities while navigating bereavement. Even when experiencing profound loneliness or sadness, participants rarely expressed grief overtly, reflecting culturally and gendered expectations for emotional control. Those who had cared for chronically ill spouses often rationalized death as a release from suffering, framing acceptance as a moral or rational stance rather than an emotional resolution. This internalized coping reflects broader evidence that men often rely on endurance and rationalization to navigate bereavement ( Dahlberg et al., 2015 ; Schmitz, 2021 ; Umberson et al., 1992 ). Such emotional restraint may protect family stability but also emphasizes the importance of providing socially and culturally acceptable outlets for grief expression. Participants did not describe prolonged grief solely by duration or intensity of sadness. Instead, disruption of daily functioning emerged as the critical criterion for recognizing grief as a mental health problem. Those who supported PGD emphasized that grief becomes pathological only when it compromises role fulfillment or daily life activities. Conversely, participants who disagreed often believed that maintaining responsibilities indicated psychological resilience, even if intense grief persisted. These findings highlight that, for men, functional threshold, rather than emotional persistence, determines when grief is perceived as a disorder, reflecting masculine norms of role performance and responsibility ( Breen et al., 2015 ; Rüsch et al., 2012 ; Tang et al., 2020 ). Seeking professional support was described as a rational, goal-oriented action rather than an expression of emotional vulnerability. Widowers sought medical or psychological assistance primarily when grief impaired their ability to fulfill social and familial obligations. Some participants also framed recovery as a moral responsibility to the deceased, emphasizing that continued preoccupation with loss could disrupt the deceased’s “peace” and the well-being of surviving family members. These findings suggest that interventions for widowers may be more effective if they are positioned as tools to restore functionality and support role continuity, rather than as purely emotional support. Together, these four dimensions form an integrated conceptual framework of widowers’ grief experiences ( Figure 1 ), demonstrating that grief is not an isolated emotional phenomenon but a socially and functionally embedded process. From a theoretical perspective, the findings extend existing grief models by highlighting that functional capacity, role performance, and relational obligations serve as central interpretive anchors through which grief is understood and managed. Compared with Western grief frameworks that emphasize emotional expression and intrapsychic processing, the present findings suggest that grief among Taiwanese widowers is more relationally and functionally oriented. While this framework captures the dominant patterns across participants, variation in individual experiences was also observed. One participant reported minimal emotional attachment to his spouse and experienced little disruption following her death. This case reveals the influence of relational context and marital intimacy on grief responses and highlights variability within widowers’ experiences. It also suggests that interventions should be sensitive to individual differences in attachment and relational history. Strengths and Limitations The study captured a broad range of bereavement experiences, offering insights into how masculinity, family responsibilities, and cultural norms shape grief. Participants’ perceptions of PGD provide valuable guidance for gender-sensitive and culturally sensitive interventions. Limitations include the recruitment of participants through clinic-attending widowers via physician referral, which may introduce potential selection bias, as these individuals may differ from widowers not engaged in clinical services. In addition, the culturally homogeneous sample, lack of socioeconomic diversity data, and geographic restriction may limit generalizability. Future research should include widowers from more diverse, non-clinical settings and consider socioeconomic variation in sampling. Implications for Practice and Research Health care providers should recognize that widowers may prioritize functional coping and role maintenance over emotional expression. Interventions should support adaptive coping strategies that align with masculine norms and family responsibilities. Public health initiatives raising awareness of PGD should consider men’s functional thresholds and pragmatic approaches to help-seeking, emphasizing that support serves both personal adjustment and family continuity. Conclusions Widowers’ grief is shaped by masculinity, family obligations, and cultural expectations, through which emotional experiences are closely tied to role performance and functional responsibilities. Rather than being expressed primarily as an individual emotional process, grief is managed through internal regulation and pragmatic help-seeking in response to functional impairment. These findings highlight the importance of understanding bereavement within culturally and gendered role contexts and emphasize the need for culturally sensitive and gender-sensitive approaches to bereavement care that address both emotional adjustment and the maintenance of role functioning and family responsibilities. Acknowledgments We would like to express gratitude to all the participants for their contribution to this research study. Footnotes ORCID iDs: Hsiang-Wan Tseng https://orcid.org/0009-0000-1742-4297 Yun-Fang Tsai https://orcid.org/0000-0002-2148-314X Ethical Considerations: This study was approved by the institutional review boards of Chang Gung Medical Foundation (202300816B0). Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Chang Gung Memorial Hospital (CMRPD1N0241). The funders had no role in data collection and analysis, selection of respondents, decision to publish, or preparation of the manuscript. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 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