Care-seeking behavior of Japanese gynecological cancer survivors suffering from adverse effects.

BACKGROUND: Post-treatment follow-up visits for gynecological cancer survivors should provide opportunities for management of adverse physical/psychological effects of therapy and early recurrence detection. However, the adequacy of such visits in Japan is poorly documented. We qualitatively explored care-seeking experiences of Japanese gynecological cancer survivors and deduced factors influencing care-seeking behaviors and treatment access. METHODS: We conducted 4 semi-structured focus groups comprising altogether 28 Japanese gynecological cancer survivors to collect a variety of participants' post-treatment care-seeking behaviors through active interaction with participants. Factors influencing access to treatment for adverse effects were analyzed qualitatively. RESULTS: Survivors sought care through specialty clinic visits when regular post-treatment gynecological follow-ups were inadequate or when symptoms seemed to be non-treatment related. Information provided by hospital staff during initial treatment influenced patients' understanding and response to adverse effects. Lack of knowledge and inaccurate symptom interpretation delayed help-seeking, exacerbating symptoms. Gynecologists' attitudes during follow-ups frequently led survivors to cope with symptoms on their own. Information from mass media, Internet, and support groups helped patients understand symptoms and facilitated care seeking. CONCLUSIONS: Post-treatment adverse effects are often untreated during follow-up visits. Awareness of possible post-treatment adverse effects is important for gynecological cancer survivors in order to obtain appropriate care if the need arises. Consultation during the follow-up visit is essential for continuity in care.

Perception of inter-professional education (IPE) among laypersons in a Japanese rural area.

Many overseas healthcare researchers have advocated the importance of inter-professional education (IPE). However, to what extent laypersons, who reside in Japanese rural areas, understand IPE is not well known. To clarify this issue, we interviewed laypersons regarding their perception of IPE. We selected one rural area in Japan, where over 40% of the residents were more than 65 years old. Participants, who had an interest in their community healthcare system, were nominated. Semi-structured interviews of approximately 60 minutes were performed and topics focused on were: 1. laypersons' perception of IPE, 2. laypersons' views on educating future medical professions, and 3. what laypersons could contribute to the educating of future medical professionals. Nine participants (58 to 88 years, 1 female and 8 males, mean 76 years) took part. We found three common themes among the interviewees. These were: 1. little knowledge about IPE, 2. positive attitudes towards educating future medical professionals, 3. original ideas concerning how to educate medical professionals. We also found that laypersons in this rural region did not fully understand IPE. As one potential educational method, we should promote IPE involving laypersons. For future study, we plan to explore medical professionals' opinions, and compare them with those of laypersons'.

Impact and characteristics of quality of life in Japanese patients with multiple sclerosis.

PURPOSE: To evaluate health-related quality of life (HRQOL) in Japanese patients with multiple sclerosis (MS) and investigate associations between the results of these QOL assessments and disease severity. METHODS: One-hundred sixty-three Japanese MS patients completed a questionnaire battery comprising the Functional Assessment of MS (FAMS), the Nottingham Adjustment Scale-Japanese version (NAS-J), and the European QOL scale (EQ-5D). Additional five factors affecting QOL as identified by MS patients in a focus group interview were also investigated: employment status, change of income, availability of disease information, communication with medical staff, and care received. Disease severity was determined using the Expanded Disability Status Scale (EDSS). RESULTS: There was a strong negative correlation of the subscale scores for mobility, symptoms, emotional well-being, thinking and fatigue, and additional concerns on the FAMS with EDSS score. For the NAS-J, only acceptance of the condition was correlated with disease severity. Among the five additional aspects of the condition identified by patients, employment status, income, and disease information were shown to be important for maintaining QOL in patients with MS. CONCLUSIONS: Support for finding employment and having increased or maintained household income and readily available information about the disease contribute to improving QOL in Japanese MS patients.

Factors in the awareness of depression, focusing on perceptual dissimilarities between PCPs and patients: an exploratory and qualitative research.

Primary care physicians (PCPs) are said to play a leading role in the early diagnosis of depression. Sometimes however, symptoms can be overlooked or misdiagnoses may occur, and this may be due to differences in the way that PCPs and patients perceive depression. The aim of this study is to clarify factors that may contribute to suspicions, or awareness of depression, focusing especially on perceptual dissimilarities between PCPs and patients. We conducted our research using qualitative methodology, with individual interviews being conducted with five experienced primary care physicians working in a rural area, and five patients who had been in consultation with PCPs. The main interview topic of this study was the triggers for their, or their patients', depression. From our interviews we discerned five categories of factors: "mental manifestations," "physical manifestations," "events in the patient's private life," "social environment and conditions" and "others." Our findings suggest that a critical difference in the perception of depression may exist between PCPs and patients. PCPs should be more alert to uncommon conditions of depression, as well as the more prevalent symptoms. We found that PCP's latent abilities and attitudes, such as "intuition," "subjectivity," and "experience", are often cues in the diagnosis of depression. This is in accordance with existing research on the subject. On the patients' side, sometimes sufferers do not notice the symptoms of depression by themselves, which may also be a serious problem. In conclusion, we, as medical professionals, must take care to be aware of these distinctions in order to swiftly detect depression, and to better treat our patients.

An interview survey on factors influencing the career choice of primary care physicians in rural areas.

BACKGROUND: The lack of primary care physicians working in rural areas is a major problem both in Japan and worldwide. Particularly in Japan, healthcare provision in the community is seriously deteriorating, due to the absence of a regulated instructional system for primary care physicians in rural areas. Understanding what influences the career choice of rural primary care physicians is vital, and this study aims to examine those factors. METHODS: Qualitative research methodology with semi-structured interviews and content analysis was used. All interviews were conducted in interviewees' rural clinics over three days in September 2007 and 2008; each interview lasted for 60 minutes. All interviews were recorded, transcribed verbatim, and analyzed thematically by two independent researchers, then the preliminary results were presented to the third and fourth authors. All authors were in agreement with the final results. RESULTS: Fourteen physicians (13 males and 1 female; mean age 43-years-old) agreed to participate in the interviews, and four themes emerged: "existence of role models for younger primary care physicians," "affinity with rural backgrounds and culture," "understanding the importance of a holistic approach," and "internal motivation for challenging and rewarding work as a doctor." DISCUSSION & CONCLUSIONS: Our research results were similar to those of previous overseas studies, regardless of differences in cultural background. We could explain our themes with the concept of the "rural pipeline into medical practice" by JP Geyman et al. according to the time frame described therein. Taking some potential limitations like generalizability and translation into account, we could utilize our research results to indicate how the number of rural primary care physicians may be increased.

The educational impact of home care in community medicine training in a Japanese medical residency program.

In light of Japan's aging society, the number of homebound people is expected to increase, and health care services for such patients will need to expand. The authors implemented a one-month pilot program in a rural hospital, which uses home care as an educational tool to further resident interns' understanding in community medicine. The program was conducted for nine medical residents. Each resident was involved in a series of eight home visits, accompanied by an experienced nurse. Upon completion, to investigate the effect of the training program, the residents were interviewed about their experiences. Responses were analyzed by using qualitative methodology. Six categories for residents' learning emerged from the analysis. They included: fostering good doctor-patient relationships while recognizing psychosocial aspects, decision-making in view of ethics and patients' preferences, the value of teamwork, medical knowledge in geriatric care, consideration of the notion of home care itself, and the significance of local characteristics. It was found that home care experience with a geriatric team can not only help deepen the residents' knowledge and skills regarding geriatric care at home, but also foster the residents' attitude toward consideration of psychosocial aspects. It was concluded that initiating a home care program is both a valuable and useful educational tool for residents in managing chronic elderly patients. Residents achieved a new viewpoint which integrated both patients' and physicians' perspectives while witnessing patients' daily lives in the community.

Factors affecting the physician-patient relationship regarding patient participation in medical encounters in primary care.

BACKGROUND: Supporting the patient's right to participate more actively in medical encounters is recommended. However, the physician-patient relationship in the context of the respect for patient participation is unclear. OBJECTIVE: To reveal the factors affecting the physician-patient relationship regarding patient participation in medical encounters in primary care. METHODS: A qualitative study incorporating a focus group interview with five female participants. They belonged to a consumer organization, which represents patients who actively participate in medical consultations. Patient behaviors, which constitute active participation, are designated as expressing their concern, asking questions, and stating their expectations in medical consultations. The recorded interview was transcribed, and analyzed with a constant comparison method. RESULTS: Four categories explaining the physician-patient relationship were extracted: Physicians' attitude; Patients' attitude; Other medical professionals' attitudes; Time environmental factors. Story lines were described; Other Medical professionals' attitudes and Time environmental factors were involved in the physician-patient relationship in accordance with the situation; Physicians' attitude and Patients' attitude had borne some mutual relations; when Patients' attitude to consultation had been active, physicians sometimes could have an aversion to these patients. CONCLUSIONS: The patients' behaviors of active participation in medical encounters contributed to physicians' aversion to patients and lead the physician-patient relationship in an unfavorable direction. Physicians' attitude is of central concern for establishing the physician-patient relationship.

A Japanese case of familial Mediterranean fever with a MEFV gene mutation.

A 17-year-old Japanese male with a three-year history of recurrent episodic chest pain and fever, each lasting for one to three days, was diagnosed with familial Mediterranean fever (FMF) because of the following: 1) short attacks of chest pain and fever recurring at varying intervals; 2) no symptoms with a sense of well-being between attacks; and 3) identification of the Mediterranean fever gene (MEFV) mutation demonstrating M6941. Although FMF has been described primarily in several limited ethnic groups, a limited number of cases have been reported in Japan. No specific diagnostic tests are commercially available for FMF so identifying the characteristic clinical picture of FMF is important.

Overexpression of the oncoprotein prothymosin alpha triggers a p53 response that involves p53 acetylation.

Activation of the tumor suppressor protein p53 is a critical cellular response to various stress stimuli and to inappropriate activity of growth-promoting proteins, such as Myc, Ras, E2F, and beta-catenin. Protein stability and transcriptional activity of p53 are modulated by protein-protein interactions and post-translational modifications, including acetylation. Here, we show that inappropriate activity of prothymosin alpha (PTMA), an oncoprotein overexpressed in human cancers, triggers a p53 response. Overexpression of PTMA enhanced p53 transcriptional activity in reporter gene assays for p53 target gene promoters hdm2, p21, and cyclin G. Overexpressed PTMA resulted in increased mRNA and protein levels for endogenous p53 target genes, hdm2 and p21, and in growth suppression. In contrast, reduction of endogenous PTMA through RNA interference decreased p53 transcriptional activity. Histone acetyltransferases (HATs) act as p53 coactivators and acetylate p53. PTMA, known to interact with HATs, led to increased levels of acetylated p53. PTMA did not increase the transcriptional activity of an acetylation-deficient p53 mutant, suggesting that p53 acetylation is an indispensable part of the p53 response to PTMA. Chromatin immunoprecipitation assays showed that excess PTMA associates with the p21 promoter and results in increased levels of acetylated p53 at the p21 promoter. Our findings indicate that overexpressed PTMA elicits a p53 response that involves p53 acetylation.

[Individual interviews with elderly in a rural area: expectations for medical care services].

INTRODUCTION: As intensive health care users, the elderly contribute significantly to rising health care cost in Japan. This research sought to elucidate the decision making processes elderly use when seeking medical care and their expectations of medical facilities and physicians. METHODS: We conducted qualitative individual interviews with rural elderly, over 65 years old, who had access to private physician offices, community, regional, and university hospitals. Interview questions elicited participants' experiences in seeking medical care; their most memorable experiences in hospitals; and their expectations for medical services. After the individual interviews, we surveyed the participants to verify the results. RESULTS: A total of 19 individuals participated in these interviews. These 19 individuals and an additional five individuals who met eligibility criteria were surveyed by mail after the interviews and verified the results. The participants identified "a feeling of intimacy" and "receiving kind-hearted treatment" as the most important attributes of medical facilities. Other important factors included: accommodating patients' preferences; being close to home; earning the patient trust; and having a well organized infrastructure. Comparatively important element were: "technology and skill", "opinion and reputation of third person", "length in the latency", "continued medical treatment by the same doctor", "actual feeling of improvement", "introduction to a higher order medical facility", "multiple medical departments", and "medical judgement by multiple doctors". These factors fall into three categories: emotional expectations; expectations of the health system; and convenience in daily life. The survey data confirmed these findings. DISCUSSION: These results suggested that elderly expect "supportive" and "accommodating" health care services in which the medical activity does not cause problems for daily life. However, these vague expectations for the medical system need translated into practical steps. Still, it is important for health care providers to consider these expectations and the relationships among them. These findings corroborate the results of a previous investigation that used focus group interviews.

[Focus group investigation on expectations of elderly people from health care facilities and physicians].

INTRODUCTION: While the elderly are intensive health care users, little is known about their expectations of various medical facilities and physicians. We investigated their views on advAntages and disadvantages of different medical settings. METHODS: We established four focus groups and surveyed elderly people living in a rural area accessible to local practitioner's offices, and community, regional, and university hospitals, The focus groups examined advantages and disadvantages of care from these facilities. A coding scheme was used to organize the data in thematic categories, In a mail survey, participants ranked the importance of specialty care; overall care; triage of patients; gentle personality; listening skills; and explanation skills, The data were analyzed for statistical differences between the various settings. RESULTS: Total of 41 elderly participated in focus groups, and 40 individuals (response rate 98%) returned statistical surveys. Advantages of care from a primary care doctor included continuity and physician accommodation of patients' preferences, while limited medical services and urgent access were disadvantages. Advantages of the community hospital included expanded medical facilities and having doctors easy to talk with, while disadvantages included lack of trust and frequent turnover. Advantages of larger facilities included extensive medical equipment, a broad range of departments and specialists, and more expert care. The survey revealed expectations for expert triage skills and familiarity with a doctor who is easy to talk with, particularly primary care doctor. DISCUSSION: These elderly subjects expect primary care and community doctors to be accessible and to exhibit excellent behavioral and communication skills, They expect more specialized and technical care in larger hospitals.

Frequency of neurotic symptoms shortly after the death of a pet.

Some individuals manifest psychosomatic symptoms after the death of their pets. A survey was conducted at four public and commercial animal cremation service centers in Japan. In each center, a questionnaire was distributed to 100 individuals (400 in total). The questionnaire consisted of the 28-item version of the General Health Questionnaire (GHQ28), the social readjustment rating scale (SRRS) and a series of questions regarding demographic information and the circumstances of their pet's death. In total, 82 returned questionnaires were available for analysis. GHQ28 proved the existence of neurotic symptoms in 46 responses (56.1%; 95% confidence interval: 44.7%-67.0%). Analysis of the responses using the GHQ28 subscales with a Likert scoring system demonstrated more somatic dysfunction in females (GHQ-A: P=0.04). Furthermore, significant correlations were identified among the following factors: owner's age (GHQ-A: ρ=-0.60, P=0.01; GHQ-B: ρ=-0.29, P=0.01; GHQ-C: ρ=-0.32, P<0.01; GHQ-D: ρ=-0.42, P<0.01), SRRS score (GHQ-A: ρ=0.32, P<0.01; GHQ-B: ρ=0.25, P=0.02; GHQ-D: ρ=0.30, P=0.01) and animal's age (GHQ-D: ρ=-0.26, P=0.02). The death of indoor pets caused deeper depression (GHQ-D: P=0.01) than that of outdoor or visiting pets. The results revealed neurotic symptoms in almost half of the pet owners shortly after their pet's death.

What primary care physician teachers need to sustain community based education in Japan.

BACKGROUND: Community based education (CBE), defined as "a means of achieving educational relevance to community needs and, consequently, of implementing a community oriented educational program," is reported to be useful for producing rural physicians in Western countries. However, why some physicians withdraw from their teaching roles is not well known, especially in Asian countries. The aim of this study was to clarify the requisites and obstacles for taking part in CBE. METHODS: WE COMBINED TWO STEPS: preliminary semi-structured interviews followed by workshop discussions. First of all, we interviewed four designated physicians (all male, mean age 48 years) working in one rural area of Japan, with less than 10,000 residents. Secondly, we held a workshop at the academic conference of the Japan Primary Care Association. Fourteen participants attending the workshop (seven male physicians, mean age 45 years, and seven medical students (one female and six male), mean age 24 years) were divided into two groups and their opinions were summarized. RESULTS: In the first stage, we extracted three common needs from interviewees; 1. Sustained significant human relationships; 2. Intrinsic motivation; and 3. Tangible rewards. In the second stage, we summarized three major problems from three different standpoints; A. Preceptors' issues: more educational knowledge or skills, B. Learner issues: role models in rural areas, and C. System issues: supportive educational system for raising rural physicians. CONCLUSIONS: Our research findings revealed that community physicians require non-monetary support or intrinsic motivation for their CBE activities, which is in accordance with previous Western studies. In addition, we found that system support, as well as personal support, is required. Complementary questionnaire surveys in other Asian countries will be needed to validate our results.

Perception of cervical cancer screening among Japanese university students who have never had a pap smear: a qualitative study.

This study aimed to explore attitudes towards cervical cancer screening among Japanese university students who had never had a Pap smear. Four focus-group discussions, each with 15 female university students, took place in November and December 2009. Discussions were recorded and transcripts were analyzed to extract attitudes of young women towards cervical cancer screening. The four themes that emerged were: i) a low sense of reality about cervical cancer; ii) a lack of knowledge about both cervical cancer and Pap smears; iii) a lack of motivation to get screened, and iv) a reluctance to visit the gynecologist. Participants who were interested in undergoing screening for cervical cancer cited the influence of conversations with friends and family, a diagnosis of cancer within their family, and relevant information from the media. The results indicate the importance of getting young women more interested in cervical cancer screening and overcoming their tendency to avoid visiting a gynecologist.

Analysis of needs of patients with idiopathic osteonecrosis of the femoral head: using focus group interviews.

AIM: The current needs of patients with idiopathic osteonecrosis of the femoral head were analyzed for the purpose of seeking effective support programs that would maintain and improve the quality of life of the patients. METHODS: A focus group interview method was used to collect data. Interviewees included eight patients. They were asked about their opinions and needs with respect to medicine, health care, and welfare. RESULTS: Overall, four needs were revealed as particularly significant: information needs, decision-making in the absence of pre-established treatment, psychological support, and sufficient medical healthcare institutions. CONCLUSION: These four needs are useful for the foundation of future support systems, whose main concerns will be: counseling support for patients with idiopathic osteonecrosis of the femoral head, currently adopted institutions, and resources that may be required in the future.

What rural physicians need to engage in community based education: a qualitative interview survey.

There is systematic evidence that community-based education is effective in the recruitment of rural physicians to remote communities. However, various obstacles may exist that prevent rural physicians from sustaining their mentoring activities. The aim of this study was to explore ways for rural physicians to overcome such adversities and continue their mentoring activities. We interviewed four nominated physicians (all male, mean age 48 years) based in Hokkaido, Japan, who practiced in an area with less than 10,000 inhabitants. Semi-structured interviews of approximately 60 minutes were performed and focused on topics rural physicians' found necessary for their teaching activities. All interviews were tape-recorded and transcribed, the verbatim transcripts were analyzed and repeated themes were identified. Three themes that emerged as needs were 1. sustained significant human relationship, including the formation of a network between students and university faculty, as well as developing partnerships with many community relationships, or other medical professions; 2. intrinsic motivations and satisfaction, including pleasure in mentoring the younger generations; and 3. rewards, including financial compensation. Rural physicians as preceptors require nonremunerative, intrinsic motivational factors, such as a sense of satisfaction regarding the education of medical students and being able to relate to residents and others health-care professions, when pursuing their educational activities. To support them, focusing only on monetary facets may be unsuccessful in encouraging them to continue their educational work.

Psychiatric investigation of 18 bereaved pet owners.

This survey explores the grief associated with the loss of a pet, and was carried out using a self-administered questionnaire. The questionnaires were handed out to 50 bereaved pet owners attending a public animal cremation service, and we received 18 responses. Participants responded within 0 to 44 (median 4) days of the death of their pet. Although most mental health problems immediately following mourning are presumed to be normal grief reactions, on the basis of several psychiatric scales, 8 of the 16 valid responses indicated depression and/or neurosis. Statistical analyses showed that the following factors were significantly associated with grief reactions: age of owner, other stressful life events, family size, age of deceased animal, rearing place, and preliminary veterinary consultation.

Incidence of Community-associated Methicillin-resistant Staphylococcus aureus Infections in a Regional Hospital.

BACKGROUND AND OBJECTIVE: Since the early 2000s, the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections among the community of people lacking known healthcare risk factors has increased. This MRSA infection is referred to as community-associated MRSA (CA-MRSA) infection and is distinct from hospital-associated MRSA (HA-MRSA) infection, which occurs among people with known healthcare risk factors. Understanding the epidemiology of CA-MRSA infections is critical; however, this has not been investigated in detail in Japan. Our objective was to investigate the incidence of CA-MRSA infections in a regional hospital. PATIENTS AND METHODS: We investigated CA-MRSA isolates and infections in a rural regional hospital by reviewing medical records of one year. Infections were classified as CA-MRSA if no established risk factors were identified. RESULTS: During 2008, 31 Staphylococcus aureus (S. aureus) isolates were detected in 29 unique patients, with 1 methicillin-sensitive S. aureus (MSSA) isolates obtained from 19 patients (66%) and MRSA obtained from 10 patients (34%). In the 10 patients with MRSA, the number of HA-MRSA and CA-MRSA cases were nine (32% of patients with S. aureus isolates) and one (3%), respectively. The patient with CA-MRSA was diagnosed with cellulitis due to CA-MRSA. All nine patients with HA-MRSA exhibited colonization. CONCLUSION: We observed a CA-MRSA case in a regional hospital in Japan, suggesting that incidence trends of CA-MRSA should be considered in future research and treatment.

Willingness to pay for municipality hospital services in rural Japan: a contingent valuation study.

BACKGROUND: The Japanese healthcare system has undergone reforms to address the struggles that municipality hospitals face. Reform guidelines clearly define criteria for administrative improvement. However, criteria to evaluate the demand for healthcare provisions in rural Japan, including the needs of rural residents for municipality hospitals in particular have not been specified. The purpose of this paper is to measure residents' willingness to pay (WTP) for municipality hospital services using the contingent valuation method, and to evaluate municipality hospital valuation on the basis of WTP. K town, located in the Hokkaido prefecture of Japan, was selected as the location for this study. Participants were recruited by a town hall healthcare administrator, hospital and clinic staff, and a local dentist. Participants were asked what amount they would be willing to pay as taxes to continue accessing the services of the municipality hospital for one year by using open-ended questions in face-to-face interviews. FINDINGS: Forty-eight residents were initially recruited, and 40 participants were selected for the study (response rate 83%). As compared to K town's population, this data slanted toward the elderly, although there was no significant difference in frequency among the characteristics. The median WTP was estimated at 39,484 yen ($438.71), with a 95% confidence interval 27,806-55,437 yen ($308.95-615.96). Logistic regression revealed no significant factors affecting WTP. CONCLUSIONS: If the total amount of residents' WTP for the municipality hospital were to be estimated by this result, it would calculate with 129,586,000 yen ($1,439,844). This is approximately equal to the amount of money to be transferred from the general account of the government of K town, more than one-half of the town tax of K town, and about two-fold in comparison to Japan as a whole. This showed that K town's residents placed a high valuation on the municipality hospital, which nearly equalled the amount that the K town government provided to the municipality hospital to cover its annual deficit. K town residents had come to expect not only general clinical practice, but also emergency medical services and night practice provided by their own town's municipality hospital. WTP can be used as a measure of hospital evaluation because it reflects the importance of the hospital to the residents in its region.