Pre-post-evaluation of a dementia-specific advance care planning toolkit for Japanese primary care clinicians.

BACKGROUND: The population of people living with dementia (PLwD) continues to grow in Japan where advance care planning (ACP) for PLwD is relatively new. Our aim was to evaluate the feasibility and cultural acceptability of a dementia-specific ACP communication skills toolkit for Japanese primary care clinicians. METHODS: We delivered 13 training sessions in primary care clinics across central Japan and conducted a post-training survey to assess whether the toolkit increased confidence in dementia-specific ACP communication skills and the acceptability of the toolkit with the following four statements: (1) The language in the sessions was clear, (2) The sessions took an appropriate amount of time to complete, (3) The design of the sessions was an effective educational method, and (4) The sessions were culturally appropriate for communication with Japanese patients with dementia and their family members. We asked participants to respond using a 5-point Likert scale from strongly agree to strongly disagree. RESULTS: All participants were Japanese and included 80 physicians (mean age 39.8 years), 33 nurses (mean age 45.7 years), and 58 other participants (mean age 42.9 years), who were 30.0%, 87.9%, and 55.2% female, respectively. Most participants practiced in rural settings. In pre- post-comparisons, participant confidence increased in determining capacity, understanding dementia prognosis, goals of care, eliciting surrogates, recommending self-care practices to families, and leading family meetings (all p < 0.001). Most participants strongly agreed or agreed that the toolkit was an effective method (96.9%), took an appropriate amount of time (94.5%), contained clear language (89.8%), and was culturally appropriate (73.6%). CONCLUSIONS: Dementia-specific ACP communication skills toolkit can be delivered in Japan. Japanese primary care clinicians generally felt the dementia-specific ACP toolkit increased their confidence in ACP communication skills and was acceptable. The language, time, and design were well received, though further work is needed to improve the cultural appropriateness of the toolkit.

Knowledge and practices of preconception care among rural Japanese women: findings from a mixed methods investigation.

BACKGROUND: Preconception care is not widespread in Japan and there is a pressing need to improve the practice. The present study assessed the knowledge and behavior of preconception care among women to seek effective intervention. Our research questions were: 1) How much do women know about preconception care? 2) How much are they practicing preconception care and what are the information sources of their behavior? 3) Do the women's preconception care behavior associated with accurate knowledge? METHODS: The research was conducted in a rural town in central Japan. Using an exploratory sequential mixed methods design, we undertook interviews, developed a survey based on the qualitative results, and then conducted a survey. The interviews explored how preconception care was perceived and practiced in women of childbearing age. The survey was designed to investigate the knowledge of preconception care among women with and without pregnancy experience, their practice behavior of preconception care, and whether the behavior is associated with knowledge. RESULTS: The participants were 13 for the interview and 232 for the survey. They had limited access to preconception care recommendations and advice for specific actions was given by obstetricians and gynecologists after pregnancy. There was a large gap in knowledge about preconception care between parous and nulliparous women, especially about the need for folic acid supplementation. Practices that were manageable in their daily lives, such as cessation of smoking and alcohol, diet, and weight management, were considered common sense. In contrast, recommended practices that require medical attention, such as screening for sexually transmitted diseases and cervical cancer, tended to be less accurately known and practiced. Participants' sources of information about preconception care were the Internet, family and friends and mass media. CONCLUSION: In rural Japan, women of childbearing age lack knowledge about preconception care, especially before their first pregnancy. Primary care providers should try outreach to schools and women's groups in the community, promote information sharing among family and close friends, and utilize information technology to enhance the knowledge and practice of preconception care.

Development and validation of a rurality index for healthcare research in Japan: a modified Delphi study.

OBJECTIVES: Rural-urban healthcare disparities exist globally. Various countries have used a rurality index for evaluating the disparities. Although Japan has many remote islands and rural areas, no rurality index exists. This study aimed to develop and validate a Rurality Index for Japan (RIJ) for healthcare research. DESIGN: We employed a modified Delphi method to determine the factors of the RIJ and assessed the validity. The study developed an Expert Panel including healthcare professionals and a patient who had expertise in rural healthcare. SETTING: The panel members were recruited from across Japan including remote islands, mountain areas and heavy snow areas. The panel recruited survey participants whom the panel considered to have expertise. PARTICIPANTS: The initial survey recruited 100 people, including rural healthcare providers, local government staff and residents. PRIMARY OUTCOME MEASURES: Factors to include in the RIJ were identified by the Expert Panel and survey participants. We also conducted an exploratory factor analysis on the selected factors to determine the factor structure. Convergent validity was examined by calculating the correlation between the index for physician distribution and the RIJ. Criterion-related validity was assessed by calculating the correlation with average life expectancy. RESULTS: The response rate of the final survey round was 84.8%. From the Delphi surveys, four factors were selected for the RIJ: population density, direct distance to the nearest hospital, remote islands and whether weather influences access to the nearest hospital. We employed the factor loadings as the weight of each factor. The average RIJ of every zip code was 50.5. The correlation coefficient with the index for physician distribution was -0.45 (p<0.001), and the correlation coefficients with the life expectancies of men and women were -0.35 (p<0.001) and -0.12 (p<0.001), respectively. CONCLUSION: This study developed the RIJ using a modified Delphi method. The index showed good validity.

Primary care physicians' perspectives and challenges on managing multimorbidity for patients with dementia: a Japan-Michigan qualitative comparative study.

BACKGROUND: Multimorbidity management can be extremely challenging in patients with dementia. This study aimed to elucidate the approaches of primary care physicians in Japan and the United States (US) in managing multimorbidity for patients with dementia and discuss the challenges involved. METHODS: This qualitative study was conducted through one-on-one semi-structured interviews among primary care physicians, 24 each from Japan and Michigan, US. Thematic and content analyses were performed to explore similarities and differences among each country's data. RESULTS: Primary care physicians in Japan and Michigan applied a relaxed adherence to the guidelines for patients' chronic conditions. Common challenges were the suboptimal consultation time, the insufficient number or ability of care-coordinating professionals, patients' conditions such as difficulties with self-management, living alone, behavioral issues, and refusal of care support. Unique challenges in Japan were free-access medical systems and not being sure about the patients' will in end-of-life care. In Michigan, physicians faced challenges in distance and lack of transportation between clinics and patients' homes and in cases where patients lacked the financial ability to acquire good care. CONCLUSIONS: To improve the quality of care for patients with multimorbidity and dementia, physicians would benefit from optimal time and compensation allocated for this patient group, guidelines for chronic conditions to include information regarding changing priority for older adults with dementia, and the close collaboration of medical and social care and community resources with support of skilled care-coordinating professionals.

Perspectives of medical students on future work-life balance in Japan: A qualitative study using postlecture comments.

Background: Recently, work-life balance (WLB) has grown in popularity among medical professionals, and an increasing number of institutions are including WLB lectures into medical school curricula. In Japan, medical student lectures concerning WLB were given in at least 50% of universities. However, with these changes in social awareness, it is not fully clear how current medical students view WLB. The purpose of this study is to explore how Japanese medical students think about their future WLB from the perspective of constructivism. Method: We used one of the present authors' work career and life cycle as an example of a physician's career in a lecture for medical students on community medicine in 2020. Students were asked to remark on their thoughts on the talk and their views on future WLB, and we analyzed their comments qualitatively to understand the current male and female medical students' perspectives on future WLB. Result: We used the feedback of 119 participants (71 males and 48 females). Most students, regardless of gender, thought WLB was essential, but the factors they mentioned as being connected to WLB mirrored the continuing traditional notions of gender-based division of labor and doctors' fixed-job image. Male students' views, on the other hand, were more varied, reflecting recent generational shifts. Conclusions: For the improved WLB in medical doctors, it would be required to tackle the problem from several angles, including not just increasing support for WLB but also fostering an awareness of the essence of WLB in pregraduate medical school.

Japanese primary care physicians' experience in treating their family members: a cross-sectional study.

BACKGROUND: Guidelines worldwide recommend that physicians should not treat their family members. However, studies in the U.S. have shown that approximately 74-83% of physicians have experience of treating family members. Primary care physicians were more likely to have such experiences than other specialists. In Japan, physicians do not have any guidelines regarding treating family members, and little is known about the experiences of primary care physicians. Therefore, we investigated the experience of treating family members or relatives among primary care physicians in Japan. METHODS: This cross-sectional study used an online questionnaire. We recruited 2,000 physicians who were members of the Japan Primary Care Association using random sampling. Data were collected from February 10 to March 10, 2021. We compare the experiences of treating family members between clinic-based doctors and hospital-based doctors using the chi-square test. We performed logistic regression analysis to adjust for gender, age, presence of a doctor in family, and physician's geographic location (rural or not rural). RESULTS: A total of 466 physicians (response rate = 23.3%) completed the survey. Of the sample, 79.8% had experience of treating family members or relatives. In the univariate analysis, being a clinic-based physician was associated with experience in treating family members compared to hospital-based physicians (87.6% vs. 74.9%, p = 0.001). Multivariable analysis showed that being a clinic-based physician (odds ratio 2.30, 95% confidence interval 1.31-4.04) and age of 45-64 years (odds ratio 2.93, 95% confidence interval 1.74-4.93) were significantly related to experience treating family. Gender and geographic location were not statistically significant factors. CONCLUSIONS: A high percentage of Japanese primary care physicians, especially those who worked in clinics, reported experience treating family members or relatives. These findings will serve as basic data for future studies regarding the care of families and relatives of physicians in Japan.

Investigating women's health issues and help-seeking intentions in primary care in Japan: a cross-sectional study.

BACKGROUND: Many women face a variety of barriers to seeing obstetricians and gynecologists (OB/GYNs). Primary care physicians (PCPs) in Japan are not well equipped to address and adequately handle women's health issues. Hence, opportunities for women to consult PCPs about women's health issues are often limited during busy outpatient encounters. It is essential to explore PCP's roles in women's health care by examining women's health needs in a primary care setting. The aim of the study is to describe the prevalence and distribution of women's health issues and help-seeking intentions among women visiting a primary care clinic. METHODS: This was a cross-sectional study using a questionnaire. We included women aged 20-60 years who visited a primary care clinic for any reason. The questionnaire comprised a list of women's health issues, the General Help Seeking Questionnaire to assess help-seeking intentions, and participants' demographics including their reasons for visiting and regularity of OB/GYN visits. RESULTS: We distributed the questionnaire to 294 women and analyzed 260 valid responses. The average age of the respondents was 40.5 years old, and they had an average of 5.2 clinic visits a year. Approximately half of them (50.4%) visited for their own care. One hundred thirty-nine (53.9%) reported at least one women's health issue, and 73.9% of them had no regular visit to an OB/GYN. The major concerns of women's health issues included gynecological cancer screenings and menstrual problems. The distribution of help-seeking intentions for each source of care appeared to be classified into three patterns. One fifth of the women indicated high help-seeking intentions for PCPs, and a greater number of women expressed higher help-seeking intentions for PCPs when they did not regularly see an OB/GYN. CONCLUSIONS: A significant number of women who visited a primary care clinic had a specific concern about women's health issues, and a majority of them had not regularly visited their OB/GYN. PCPs may have an important role in providing an opportunity for women to discuss their concerns about women's health issues as part of comprehensive care during a daily clinical encounter.

[Factors related to the awareness of hope at the end of life among older adults who attend community-based preventive services for long-term care].

INTRODUCTION: This study explored the factors related to awareness of hope at the end of life among older adults who attend community-based preventive services for long-term care. METHODS: Hope at the end of life was determined using a six-item questionnaire inquiring about topics such as "Medical hope when oral intake is not possible" and "Where they wanted to spend the end of their lives." A multiple logistic regression analysis was performed using the six items as dependent variables and hospitalization experience, end-of-life care experience, and one's view of life and death as independent variables. RESULTS: Data from 95 retrieved questionnaires were analyzed. The range of hope at the end of life was 14.7%-71.6% for each item. "Where they wanted to spend the end of their lives" was the most frequently considered topic among the respondents. "Medical hope when oral intake was not possible" was considered by 41.1% of respondents, and this topic was related to experience with hospitalization and end-of-life care as well as interest in death. CONCLUSION: Hospitalization experience, end-of-life care, and personal views on life and death were shown to be related to awareness of hope at the end of life among community-dwelling older adults.

Intergenerational Theater Workshops as Unique Recreational Activities among Older Adults in Japanese Care Facilities: A Qualitatively Driven Mixed-Methods Multiple-Case Study Design.

Intergenerational theater activities have been recently employed in recreation for older adults. We held a series of four intergenerational theater workshops in two older adults' care facilities in Japan and sought the experiences of older participants, younger participants, and the facility managers. With a qualitatively driven mixed-methods multiple-case study design, we obtained data from field observation, interviews with participants, and preworkshop and postworkshop changes on a well-being scale (Ikigai-9) among older participants, and the results of the two sites were compared. "Immediate effects" were seen in older adults because they responded actively and demonstrated surprising faculties during the workshop. Facility staff members and younger participants received "extended effects" because they gained new ideas regarding the remaining skills of older participants and a sense of reuniting with old neighbors through the exercise. In the Ikigai-9 scale, the items measuring "present happiness" significantly improved at Site 1 but not at Site 2. Better results at Site 1 might have been caused by the lower care needs of participants and the inclusion of children. Less support from facility staff members during the activities also might have promoted the voluntary participation of older adults. Involving children and engaging the facility staff in preparation could enhance the quality of activities.

Development and validation of a Japanese version of the person-centered primary care measure.

BACKGROUND: Although primary care (PC) is an indispensable part of the health system, measuring its quality is challenging. A recent measure of PC, Person-Centered Primary Care Measure (PCPCM), covers 11 important domains of PC and has been translated into 28 languages. This study aimed to develop a Japanese version of the PCPCM and assess its reliability and validity. METHODS: We employed a cross-sectional mail survey to examine the reliability and content, structure, criterion-related, and convergent validity of the Japanese version of the PCPCM. This study targeted 1000 potential participants aged 20-74 years, selected by simple random sampling in an urban area in Japan. We examined internal consistency, confirmatory factor analysis, correlation between the Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF), and the association between the PCPCM score and influenza vaccine uptake. RESULTS: A total of 417 individuals responded to the survey (response rate = 41.7%), and we used the data of 244 participants who had the usual source of care to assess the reliability and validity of the PCPCM. Confirmatory factor analysis demonstrated sufficient structural validity of the original one-factor structure. The overall Cronbach's alpha was 0.94. The Spearman correlation coefficient between PCPCM and JPCAT-SF was 0.60. Influenza vaccine uptake was not significantly associated with total PCPCM score. CONCLUSIONS: The study showed that the Japanese version of the PCPCM has sufficient internal consistency reliability and structural- and criterion-related validity. The measure can be used to compare the quality of primary care in Japan and other countries.

Differences between frequent emergency department users in a secondary rural hospital and a tertiary suburban hospital in central Japan: a prevalence study.

OBJECTIVES: Although frequent emergency department (ED) use is a global issue, little research has been conducted in a country like Japan where universal health insurance is available. The study aims to (1) document the proportion of ED visits that are by frequent users and (2) describe the differences in characteristics of frequent ED users and other ED users including expenditures between a secondary and a tertiary hospital. DESIGN: A prevalence study for a period of 1 year. SETTING: A secondary hospital and a tertiary hospital in central Japan. PARTICIPANTS: All patients who presented to the EDs. PRIMARY OUTCOME MEASURES: We defined frequent ED user as a patient who visited the ED≥5 times/year. The main outcome measures were the proportion of frequent ED users among all ED users and the proportion of healthcare expenditures by the frequent ED users among all ED expenditures. RESULTS: Of 25 231 ED visits over 1 year, 134 frequent ED users accounted for 1043 visits-0.66% of all ED users, comprised 4.1% of all ED visits, and accounted for 1.9% of total healthcare expenditures. Median ED visits per one frequent ED user was 7.9. At the patient level, after adjusting for age, gender and receiving public assistance, older age (OR 1.01, 95% CI: 1.00 to 1.02) and receiving public assistance (OR 7.19, 95% CI 2.87 to 18.07) had an association with frequent ED visits. At the visit-level analysis, evaluation by internal medicine (OR 1.27, 95% CI 1.02 to 1.57), psychiatry (OR 124.69, 95% CI 85.89 to 181.01) and obstetrics/gynaecology (OR 2.77, 95% CI 2.09 to 3.67) were associated with frequent ED visits. CONCLUSION: The proportion of frequent ED users, of total visits, and of expenditures attributable to them-while still in the low end of the distribution of published ranges-are lower in this study from Japan than in reports from many other countries.

Perspectives on disclosure of the dementia diagnosis among primary care physicians in Japan: a qualitatively driven mixed methods study.

BACKGROUND: The number of dementia patients in Japan is projected to reach seven million by 2025. While modern ethicists have largely reached the conclusion that full disclosure of dementia serves the best interest of patient, the implications of disclosure of a dementia diagnosis remains an underexplored area of research in Japan. The purpose of this study was to explore primary care physicians' perspectives relative to the practice of disclosure of the dementia diagnosis. METHODS: In this qualitatively driven mixed methods project, we conducted semi-structured interviews with 24 primary care physicians using purposeful sampling to identify rural and urban representation. All interview recordings were transcribed verbatim and analyzed thematically. The research team iteratively conducted discussions of the concepts as they emerged until reaching thematic saturation. The summary was distributed to the participants for member checking and we incorporated their feedback into the final analysis. RESULTS: Of 24 participants, 12 practice in rural areas and 12 practice in urban/suburban areas. Participants' attitudes varied in whether or not to disclose dementia diagnosis to the patients, and in the level of clarity of the name and the prognosis of the disease. Participants who were more comfortable in practicing disclosure were communicating collectively to the patients and their family members and those who were less comfortable practicing disclosure were concerned about patients' feelings and had negative perceptions given the insidious progression of the disease. CONCLUSION: We found substantive individual differences in the approach to disclosure of the diagnosis of dementia and the level of comfort among primary care physicians. More dialogue about this issue and training to equip primary care physicians lacking confidence in their approach may be required.

Admissions for ambulatory care sensitive conditions on rural islands and their association with patient experience: a multicentred prospective cohort study.

OBJECTIVES: The rate of admissions for ambulatory care sensitive conditions (ACSCs) is a key outcome indicator for primary care, and patient experience (PX) is a crucial process indicator. Studies have reported higher rates of admission for ACSCs in rural areas than in urban areas. Whether there is an association between admissions for ACSCs and PX in rural areas has not been examined. This study aimed to document admissions for ACSCs on Japanese rural islands, and assess whether there was an association between the rate of admissions for ACSCs and PX. DESIGN: Multicentred, prospective, cohort study SETTING: This study was conducted on five rural islands in Okinawa, Japan. PARTICIPANTS: The study participants were all island inhabitants aged 65 years or older. PRIMARY OUTCOME MEASURES: This study examined the association between ACSCs and PX assessed by a questionnaire, the Japanese Version of Primary Care Assessment Tool. ACSCs were classified using the International Classification of Diseases, Tenth Revision, and the rate of admissions for ACSCs in 1 year. RESULTS: Of 1258 residents, 740 completed the questionnaire. This study documented 38 admissions for ACSCs (29 patients, males/females: 15/14, median age 81.9) that included congestive heart failure (11), pneumonia (7) and influenza (5). After adjusting for covariates and geographical clustering, admissions for ACSCs had a significant positive association with each patient's PX scores (OR per 1 SD increase=1.62, 95% CI 1.02-2.61). CONCLUSIONS: Physicians serving rural areas need to stress the importance of preventive interventions for heart failure, pneumonia and influenza to reduce the number of admissions for ACSCs. Contrary to previous studies, our findings might be explained by close patient-doctor relationships on the rural islands.

Gender-Based Risk and Protective Factors for Psychological Distress in the Midterm Recovery Period Following the Great East Japan Earthquake.

OBJECTIVES: Women and men might experience psychological distress differently during a disaster. This study investigated gender differences in the factors associated with psychological distress among working-age people 1 to 2 years after the Great East Japan Earthquake. METHODS: A cross-sectional household survey of victims who remained living in their homes was conducted between May and December 2012 in Ishinomaki City, Japan. Psychological distress was defined as a Kessler Psychological Distress Scale ≥5, and gender differences were examined using a logistic regression analysis. RESULTS: Data were obtained from 2593 individuals, and 1537 participants were included in the analyses. Psychological distress was observed in 28.0% of the participants. Living in a household without a salaried income and a low frequency of leaving the house were associated with psychological distress among women. Young age, lack of occupation and no informational support were associated with psychological distress among men. Income change due to the disaster and health complaints were associated with psychological distress in both genders. CONCLUSIONS: For women, stable household income and frequently leaving the house can be protective factors. For men, intervention focusing on young people, occupational support, and informational support may be useful. Income change after the disaster and health complaints may be risk factors in both genders. (Disaster Med Public Health Preparedness. 2019;13:487-496).

Associations of Patient Experience in Primary Care With Hospitalizations and Emergency Department Visits on Isolated Islands: A Prospective Cohort Study.

PURPOSE: In rural areas, the management of hospitalizations and emergency department (ED) visits is an important issue, and it is compounded by factors such as the long distance to secondary care facilities, funding difficulties in many rural medical institutions, and shortage of medical staff. While better patient experience (PX) has been shown to reduce hospitalizations and ED visits, previous studies have not considered the differences between urban and rural areas. In addressing this gap, this study examines the association between PX and hospitalizations/ED visits on isolated islands. METHODS: This prospective cohort study was conducted on 5 isolated islands in Okinawa, Japan. We assessed the PX of primary care using the Japanese version of the Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was hospitalizations and ED visits in a year. We used a mixed effect model to adjust clustering within islands and individual covariates. FINDINGS: Of 1,258 residents, 740 responded to a questionnaire for PX measurement. There were 73 hospitalizations and 62 ED visits. Adjusting for confounding and geographical clustering, hospitalizations had significant positive association with the PX score of each patient. ED visits were not associated with the total score of the JPCAT. CONCLUSION: On the isolated islands, PX in primary care had positive correlation with hospitalizations. The contrast of our findings to those of previous studies may be due to the close patient-doctor relationship on isolated islands.

An analysis of qualitative and mixed methods abstracts from Japanese, UK and US primary care conferences.

BACKGROUND: As research in family medicine covers varied topics, multiple methodologies such as qualitative research (QR) and mixed methods research (MMR) are crucial. However, we do not know about the difference in the proportion of QR or MMR between Japan, the UK and the US. This knowledge is needed to shape future research within countries with developing primary care such as Japan and other Asian countries. This study aims to describe the use of QR and MMR in Japanese primary care and compare this to the UK and US; then to make informed recommendations for primary care research. METHODS: A repeated cross-sectional study (2012-2016) based on the abstracts submitted to the annual conferences of the Japanese Primary Care Association in Japan, the Royal College of General Practitioners in the UK, and the North American Primary Care Research Group in the US and other North American countries. The proportions of QR/MMR among all the posters and paper presentations for each of these three conferences were assessed. Also examined were trends and types of qualitative techniques for all three countries and participants/settings for Japan. RESULTS: There were 1080 abstracts for Japan, 575 for UK and 3614 for US conferences. QR/MMR proportions were 7.5%, 15.1% and 28.1%, respectively. Japan's proportion was lower than that of UK and US (p < 0.001). The proportion was increasing over time for the UK (p = 0.02). Steps for coding and analyses was most popular for Japan, thematic analysis for the UK and grounded theory for the US. Primary care doctors and hospitals were the commonest contexts for Japan. CONCLUSIONS: QR and MMR were not as popular in primary care in Japan compared to the UK and the US, whereas their use was increasing in the UK. Approaches, participants and settings may differ among these countries. Education and promotion of QR/MMR and multi-disciplinary collaborations need to be recommended in Japan with developing primary care.

Correlation between family physician's direct advice and pneumococcal vaccination intention and behavior among the elderly in Japan: a cross-sectional study.

BACKGROUND: Vaccination is an important element of health maintenance in family medicine. The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is highly recommended for the elderly, but its uptake is low in Japan. Primary care system remains under development and preventive services tend to be neglected in the Japanese medical practice. The study aims to investigate the association between family physician's recommendations for PPSV23 during outpatient care and PPSV23 vaccination intention and behavior in the elderly. METHOD: We conducted a cross-sectional study with a questionnaire at a family medicine clinic in a rural area in Japan. The participants were over the age of 65 without dementia who had maintained a continuity with the clinic. The questionnaire inquired PPSV23 vaccination status, family physician's advice for PPSV23, socio-demographics, and the constructs in the Health Belief Model. We defined those who had had vaccination intention and behavior as "PPSV23 vaccinated group" and those who had no vaccination and uncertainty about being or no intention to be vaccinated in the future as "PPSV23 unvaccinated group." We used chi-square test for correlation between physician's advice and PPSV23 vaccination/intention, univariate and multivariate logistic regression analysis for factors related to the vaccination/intention, and descriptive analysis for reasons for reluctance to the vaccination. RESULTS: We analyzed 209 valid responses. There were 142 participants in the PPSV23 vaccinated group and 67 in the PPSV23 unvaccinated group. The PPSV23 vaccination group was more likely to have had their physician's advice (80.2% vs 21.3%, p < 0.001). Multivariate logistic regression analysis showed a significant association between PPSV23 vaccination and their physician's recommendation (OR 8.50, 95%CI 2.8-26.0), awareness of PPSV23 (OR 8.52, 95%CI 2.1-35.0), and the perceived effectiveness of PPSV23 (OR 4.10, 95%CI 1.2-13.9). The reasons for reluctance to get vaccinated included lack of understanding of PPSV23, lack of physician's recommendations, and concerns about side effects of PPSV23. CONCLUSION: Family physician's recommendation was positively correlated with PPSV23 vaccination intention and behavior in the elderly. This reinforces the importance of providing preventive services during time-constrained outpatient care, even in medical systems where it is undervalued.

Challenges in providing maternity care in remote areas and islands for primary care physicians in Japan: a qualitative study.

BACKGROUND: Maintaining a maternity care system is one of the biggest issues in Japan due to the decreasing number of obstetricians, especially in remote areas and islands. The aim of this qualitative study was to explore the challenges in women's health and maternity care in remote areas and islands for primary care physicians and obstetricians in order to provide an insight necessary to develop a better health care system. METHODS: We conducted semi-structured interviews with 13 primary care physicians and 4 obstetricians practicing maternity care at clinics/hospitals in remote areas and islands across Japan. Interview data were analyzed, using the modified Grounded Theory Approach, to elucidate the challenges primary care physicians faced in their practice. RESULTS: Primary care physicians who engaged in maternity care recognized the following challenges: low awareness of primary care, lack of training opportunities, unclear goal of the training, lack of certification system, lack of consultation system, and lack of obstetricians to offer support. These six challenges along with the specialty's factors such as sudden changes of patients' condition were considered to result to the provider's hesitation and anxiety to engage in the practice. CONCLUSIONS: This study found six environmental/systemic factors and three specialty's factors as the main challenges for primary care physicians in providing maternity care in remote areas and islands for primary care physicians in Japan. Increasing the awareness of primary care and developing a maternity care training program to certify primary care physicians may enable more primary care physicians to engage in and provide women's health and maternity care in remote areas and islands.

Association between health literacy and patient experience of primary care attributes: A cross-sectional study in Japan.

Primary care is regarded as a setting that potentially mitigate patient health literacy (HL) related inequalities. However, there is a lack of evidence about influence of patient HL on the patients' perception of quality of primary care. We aimed to examine the association between HL and patient experience of primary care attributes. We conducted a cross-sectional survey, and sent questionnaires to adult residents who were randomly selected from a basic resident register in Yugawara Town, Kanagawa, Japan. We assessed HL using a 14-item Health Literacy Scale (HLS-14) and patient experience of primary care attributes using a Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. We used a multivariable linear regression analyses to adjust individual covariates. Data were analyzed for 381 residents who had a usual source of care. After adjustment for patients' sociodemographic and health characteristics, patient HL was positively associated with the JPCAT total score (B = 4.49, 95% confidence interval: 0.27 to 8.65 for HLS-14 total score highest quartile, compared with the lowest quartile). Among primary care attributes, HL had significant associations with longitudinality and comprehensiveness (service provided). We found that HL was positively associated with patient experience of primary care attributes in Japanese people. Our findings indicated that greater efforts might be needed to improve patient-centered and tailored primary care to those with low HL.