Assessing Social Circumstances in Primary Care: Expert Consensus via Delphi Technique.

Background and Objective: In the Japanese primary care setting, a set of questions to screen patients' social circumstances has never been developed in a scientific manner. This project aimed to reach a consensus among diverse experts to develop a set of such questions, to meet the need for assessing patients' health-related social circumstances. Methods: We used a Delphi technique to generate expert consensus. The expert panel was composed of various clinical professionals, medical trainees, researchers, support members for marginalized people, and patients. We conducted multiple rounds of communication online. In round 1, the participants provided their opinions about what health care professionals should ask to assess patients' social circumstances in primary care settings. These data were analyzed into several themes. In round 2, all themes were confirmed by consensus. Results: Sixty-one people participated in the panel. All participants completed the rounds. Six themes were generated and confirmed: economic condition and employment, access to health care and other services, living in everyday life and leisure time, total physiological needs, tools and technology, and history of the patient's life. In addition, the panelists emphasized the importance of respecting the patient's preferences and values. Conclusion: A questionnaire, abbreviated by the acronym of HEALTH+P, was developed. Further research about its clinical feasibility and impact on patient outcomes is warranted.

Competency lists for urban general practitioners/family physicians using the modified Delphi method.

BACKGROUND: In recent years, the growing global urbanization and urban population have resulted in the emergence of various health problems unique to urban areas. Therefore, training general practitioners and family physicians who can tackle the complex health problems of urban areas and improve the health of urban people is one of the most important issues of our time. However, findings on competencies for urban general practitioners (GP) and family physicians (FP) were limited. This study aimed to identify their comprehensive and content-validated list of competencies. METHODS: We used the modified Delphi method to develop a content-validated competency list. First, we analyzed and synthesized the competencies extracted from the literature review using qualitative thematic analysis methods to create an initial competency list of 34 items. We then assembled 39 expert panelists in four groups of study participants: physicians, nurses, patients, and medical education specialists. The expert panelists were asked to indicate their level of agreement with the lists and provide revised comments on the description of each competency via a web-based questionnaire. Their responses were analyzed quantitatively and qualitatively by the research team and used to revise the list. These processes were repeated, and the survey was completed when it was determined that consensus had been reached. RESULTS: Three rounds of Delphi were conducted. 39 responded in the first round, 38 in the second round, and 36 in the third round. The initial list of competencies was revised and consolidated from 34 to 14 items in the first round, bringing the total to 20 items along with six new items proposed by the panelists. In the second round, it was revised and consolidated into a list of 18 items. In the third round, all 18 items were considered to have been agreed upon by the panelists, so the survey was closed. CONCLUSION: We identified a comprehensive 18-item list of competencies for urban GP/FP in a content-validated manner. Several are newly discovered competencies in this study. The findings of this study will be useful for the future training of urban GP/FP and for solving urban health problems.

Primary care physicians' perceptions of social determinants of health recommendations: a qualitative study.

BACKGROUND: Several organisations have called for primary care professionals to address social determinants of health (SDoH) in clinical settings. For primary care physicians to fulfill their community health responsibilities, the implications of the SDoH recommendations need to be clarified. AIM: To describe primary care physicians' views about being asked to address SDoH in clinical settings, from both positive and negative perspectives. DESIGN & SETTING: A qualitative study in Japan. Twenty-one physicians were purposively recruited. METHOD: 'Love and breakup letter' methodology was used to collect qualitative data that contained both positive and negative feelings. Participants wrote love and breakup letters about being asked to address SDoH in a clinical setting, then undertook an in-depth online interview. Data were analysed via thematic analysis using the framework approach. RESULTS: The following themes were identified: (i) primary care physicians take pride in being expected to address SDoH; (ii) primary care physicians rely on the recommendations as a partner, even in difficult situations; (iii) primary care physicians consider the recommendations to be bothersome, with unreasonable demands and challenges, especially when supportive surroundings are lacking; and (iv) primary care physicians reconstruct the recommendations on the basis of their experience. CONCLUSION: Primary care physicians felt both sympathy and antipathy towards recommendations asking them to address SDoH in their clinical practice. The recommendations were not followed literally, instead contributing to physicians' clinical mindlines. Professional organisations that plan to develop and publish recommendations about SDoH should consider how their recommendations might be perceived by their target audience.

Defining the observable processes of patient care related to social determinants of health.

INTRODUCTION: An understanding of social determinants of health (SDH) and patients' social circumstances is recommended to deliver contextualised care. However, the processes of patient care related to SDH in clinical settings have not been described in detail. Observable practice activities (OPAs) are a collection of learning objectives and activities that must be observed in daily practice and can be used to describe the precise processes for professionals to follow in specific situations (process OPA.) METHODS: We used a modified Delphi technique to generate expert consensus about the process OPA for patient care related to SDH in primary care settings. To reflect the opinions of various stakeholders, the expert panel comprised clinical professionals (physicians, nurses, public health nurses, social workers, pharmacists and medical clerks), residents, medical students, researchers (medical education, health care, sociology of marginalised people), support members for marginalised people and patients. The Delphi rounds were conducted online. In Round 1, a list of potentially important steps in the processes of care was distributed to panellists. The list was modified, and one new step was added. In Round 2, all steps were acknowledged with few modifications. RESULTS: Of 63 experts recruited, 61 participated, and all participants completed the Delphi rounds. A total of 14 observable steps were identified, which were divided into four components: communication, practice, maintenance and advocacy. The importance of ongoing patient-physician relationships and collaboration with professionals and stakeholders was emphasised for the whole process of care. DISCUSSION: This study presents the consensus of a variety of experts on the process OPA for patient care related to SDHs. Further research is warranted to investigate how this Communication-Practice-Maintenance-Advocacy framework could affect medical education, quality of patient care, and patient outcomes.

Primary care nurses during the coronavirus disaster and their struggle: Qualitative research.

Background: Coronavirus disease 2019 (COVID-19) has substantially affected the health and lives of medical professionals. However, the experiences of nurses engaged in primary care remain unclear. We explored how nurses working in primary care were psychologically and socially affected by the COVID-19 disaster and how they overcame the difficulties experienced. Methods: We conducted a qualitative study of seven Japanese nurses working in primary care. Data collection was performed before, during, and after a workshop based on the Tojisha-Kenkyu (user-led research) framework to explore how the COVID-19 disaster affected the nurses and how they coped. Data were analyzed using inductive thematic analysis. Results: Three themes emerged from the analysis: effects of the COVID-19 disaster on nurses, nurses' newly found strength during the pandemic, and their changes and achievements through the Tojisha-Kenkyu framework. The first theme comprised four subthemes: fear of the unknown; difficulty in adaptation; dysfunction in patient care; and defilement and oppression. The second theme involved feeling in control and professionalism. The third theme, which was based on participants' discovery of "same and different" fellowships, showed work reconstruction and self-understanding, which alleviated their difficulties. Conclusions: The effect of the pandemic on nurses working in primary care ranges from work-related frustration to daily life issues. The Tojisha-Kenkyu method can help nurses to alleviate difficulties. Further research should be conducted to elucidate the constant burden on primary care professionals and establish appropriate occupational and daily life support during pandemics.

Development and Validation of a Performance Assessment Checklist Scale for Vaccine Administration.

Objective Vaccination technique is a crucial skill for medical trainees to learn, especially in the current coronavirus disease 2019 pandemic. To this end, validated assessment tools are essential in teaching appropriate techniques. However, valid instruments for assessing vaccine administration skills have not yet been developed. We therefore explored the development and validation of an assessment tool for vaccination techniques based on expert consensus. Methods We implemented a modified Delphi process to develop a vaccination technique assessment tool. We then conducted a validation study to establish the reliability and validity of the tool. Results Two rounds of the modified Delphi process were performed to generate a 19-item, vaccination performance assessment checklist. In the validation study, the linear weighted kappa value for inter-rater reliability of the overall checklist score was 0.725. Spearman's correlation coefficient between the mean checklist score and the global rating was 0.98 (p<0.01). Conclusions This is a pioneering study examining the development and validation of an assessment tool for vaccine administration techniques. The tool will be widely used in vaccination-related education.

Competencies required for general practitioners/family physicians in urban areas versus non-urban areas: a preliminary study.

BACKGROUND: The medical practice of general practitioners/family physicians in urban areas differs from that in rural areas, accounting for the difference in specific competencies. However, variations in competencies in community healthcare required for general practitioners/family physicians in urban areas compared with those in rural areas have not yet been fully clarified. Thus, this study aimed to elucidate the competencies required for general practitioners/family physicians, especially in those characteristic to urban areas, and compare them with those in non-urban/rural areas. METHODS: A qualitative study with individual interviews and qualitative data analysis was conducted. Participants were selected by purposive sampling, and 10 general practitioners/family physicians with clinical experience of ≥7 y after graduation and ≥ 1 y in both urban and non-urban (rural) areas in Japan were recruited. Additionally, semi-structured individual interviews in a private room around the workplace of the interviewee between September 2014 and September 2016 were conducted. For data collection, interview transcripts were analyzed according to the "Steps for Coding and Theorization" method, a sequential and thematic qualitative data analysis technique and data analysis since March 2018. RESULTS: We interviewed 10 general practitioners/family physicians of Japan and extracted 10 themes as competencies characteristic to general practitioners/family physicians in urban areas. In addition to the known competencies on urban underserved care, we newly clarified the competencies of the ability to integrate divided care and ability to coordinate and collaborate with various medical care and welfare professionals in urban areas. CONCLUSION: This study was one of the few studies describing the characteristic competencies of urban general practitioners. In summary, a competency necessary for general practitioners in urban areas is to understand the urban context and provide contextual care suitable for urban areas. In the modern age, where urban population concentration is progressing and the interest in urban health is rising, our study will give certain suggestions for primary care education and practice necessary for urban areas.