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1.
PLoS One ; 14(1): e0210912, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30653563

RESUMEN

Interprofessional education (IPE) for medical students is becoming increasingly important, as reflected in the increasing number of medical schools adopting IPE. However, the current status of and barriers to pre-registration IPE implementation in Japanese medical schools remain unknown. The purpose of this study was to clarify the status and barriers of IPE implementation in medical schools in Japan. We conducted a curriculum survey from September to December 2016 of all 81 medical schools in Japan. We mailed the questionnaire and asked the schools' undergraduate education staff to respond. The survey items were the IPE implementation status and barriers to program implementation. Sixty-four of the 81 schools responded (response rate 79.0%), of which 46 (71.9%) had implemented IPE, 42 (89.1%) as compulsory programs. Half of IPE programs were implemented in the first 2 years, while less than 10% were implemented in the latter years of medical programs. As part of the IPE programs, medical students collaborated with a wide range of professional student groups. The most common learning strategy was lectures. However, one-third of IPE programs used didactic lectures without interaction between multi-professional students. The most common perceived major barrier to implementing IPE was adjustment of the academic calendar and schedule (82.8%), followed by insufficient staff numbers (73.4%). Our findings indicate that IPE is being promoted in undergraduate education at medical schools in Japan. IPE programs differed according to the circumstances of each school. Barriers to IPE may be resolved by improving learning methods, introducing group discussions between multi-professional students in lectures or introducing IPE programs using team-based learning. In summary, we demonstrated the current status and barriers of IPE implementation in Japanese medical schools. Our findings will likely lead to the promotion of IPE programs in Japan.


Asunto(s)
Educación de Pregrado en Medicina/métodos , Relaciones Interprofesionales , Facultades de Medicina , Curriculum , Humanos , Japón , Encuestas y Cuestionarios
2.
Rural Remote Health ; 18(4): 4840, 2018 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-30365899

RESUMEN

INTRODUCTION: In Japanese medical schools, a special regional quota (chiikiwaku) system has been widely implemented to increase the number of physicians in medically underserved areas (MUAs). Regional quota students are required to take out a student loan but are exempted from repayment after fulfilling an approximately 9-year obligatory practice period. This study investigated the anticipated willingness of final-year regional quota students to remain in MUAs after their obligatory practice period, as well as factors associated with this willingness during students' first year. METHODS: The participants in this prospective observational study were all regional quota students at Japanese medical schools. Baseline data were collected when students were in their first year, and their anticipated willingness to remain in MUAs after their obligatory practice period was the primary outcome, determined by questionnaire during the students' final year. The association between baseline data and willingness to remain in MUAs was analyzed by the Χ2 test and logistic regression analysis. RESULTS: At baseline, 405 first-year students in 38 medical schools answered the questionnaire; of these, 208 (51.4%) students were followed up 5 years later. The proportion of regional quota students who anticipated being willing to remain in MUAs decreased from 52.3% to 19.2% after 5 years. In multivariate analysis, anticipated willingness to remain in MUAs in the sixth year was associated with rural upbringing (odds ratio (OR) 2.1), influence of income on work preference (OR 0.3) and willingness to remain in MUAs as assessed during the first year (OR 3.3). CONCLUSIONS: Regional quota students' anticipated willingness to remain in MUAs decreased as they progressed through medical school. To increase the number of physicians in MUAs, it may be useful to recruit regional quota students who come from rural areas, who do not place a high priority on expected incomes, and who initially anticipate a willingness to remain in MUAs.

3.
J Gen Fam Med ; 19(3): 97-101, 2018 May.
Artículo en Inglés | MEDLINE | ID: mdl-29744263

RESUMEN

Objective: To assess the extent to which long-term care facilities in Japan adhere to blood pressure (BP) measurement guidelines. Design: Cross-sectional, observational survey. Setting: Japan (nationwide). Participants: Geriatric health service facilities that responded to a questionnaire among 701 facilities that provide short-time daycare rehabilitation services in Japan. Methods: A written questionnaire that asked about types of measurement devices, number of measurements used to obtain an average BP, resting time prior to measurement, and measurement methods when patients' arms were covered with thin (eg, a light shirt) or thick sleeves (eg, a sweater) was administered. Main outcome measure: Proportion of geriatric health service facilities adherent to BP measurement guidelines. Results: The response rate was 63.2% (443/701). Appropriate upper-arm BP measurement devices were used at 302 facilities (68.2%). The number of measurements was appropriate at 7 facilities (1.6%). Pre-measurement resting time was appropriate (≥5 minutes) at 205 facilities (46.3%). Of the 302 facilities that used appropriate BP measurement devices, 4 (1.3%) measured BP on a bare arm if it was covered with a thin sleeve, while 266 (88.1%) measured BP over a thin sleeve. When arms were covered with thick sleeves, BP was measured on a bare arm at 127 facilities (42.1%) and over a sleeve at 78 facilities (25.8%). Conclusions: BP measurement guidelines were not necessarily followed by long-term care service facilities in Japan. Modification of guidelines regarding removing thick sweaters and assessing BP on a visit-to-visit basis might be needed.

4.
J Clin Med Res ; 10(3): 226-232, 2018 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-29416582

RESUMEN

Background: Burnout in attending physicians is a crucial issue that may negatively impact patient outcomes, as well as affect the quality of training provided to residents. To investigate the association between burnout and stress-coping ability, we conducted a cross-sectional study of attending physicians. Methods: From April 2013 to March 2014, we distributed an anonymous, self-administered questionnaire to 1,897 attending physicians who attended teaching-related training sessions and workshops. The questionnaire included the Maslach Burnout Inventory General Survey (MBI-GS, Japanese version) to evaluate burnout; the sense of coherence scale (SOC, Japanese version) to measure stress-coping ability, with higher scores indicating higher stress-coping ability; the Brief Scales for Job Stress (BSJS) to assess stress and buffering factors; demographic factors; mean weekly working hours; and factors related to instructing residents. The MBI-GS was used to determine the presence of physician burnout. Subjects were divided into tertiles based on SOC scores. We conducted logistic regression analysis of burnout using the following independent variables: physician experience, sex, mean weekly working hours, SOC group, mental workload, and reward from work. Results: Of the 1,543 (81.3%) attending physicians who responded, 376 did not meet the inclusion criteria and 106 had missing data, thus 1,061 (55.9%) were analyzed. The prevalence of burnout was 17.2%. Physicians with burnout had significantly fewer years of experience as a doctor (P < 0.01), were more likely to be female (P < 0.01), worked more hours per week (P < 0.01), and had a lower SOC score (P < 0.01) than physicians without burnout. On the BSJS, the mean score of all stress factors was higher and that of buffering factors was lower in physicians with burnout (P < 0.01). The percentages of physicians with burnout were 35.7%, 12.8%, and 3.2% in the low, middle, and high SOC groups, respectively (P < 0.01). Using the high SOC group as a reference, the adjusted odds ratio for burnout in the low SOC group was 4.7 (95% confidence interval: 2.31 - 9.63) (P < 0.01). Conclusions: In this study, burnout among attending physicians was significantly associated with SOC scores after adjustment for stress factors and buffering factors.

5.
Blood Press Monit ; 23(1): 9-11, 2018 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-28926363

RESUMEN

OBJECTIVE: Blood pressure (BP) measurement is recommended on bare arms, but undressing the arms for BP measurements is often difficult for frail elderly individuals. We aimed to assess the accuracy of BP measurements over arms with thin and thick clothing among the frail elderly. PARTICIPANTS AND METHODS: This is a cross-sectional study. Individuals aged 65 years or older were recruited from three long-term care facilities in Japan between April and May 2016. The main outcome measures were BP measurements (a) on a bare arm, (b) over a thin shirt, (c) over a thin shirt and a cardigan, and (d) over the sleeve of a thin shirt and a cardigan rolled up to the elbow. BP was compared across measurements using the paired t-test and multiple analysis of variance adjusting for sex and treatments for hypertension. RESULTS: Of 147 participants, 23.8% were men. The mean age of the participants was 87.2 years (SD: 7.8). The mean (SD) BP on a bare arm, over a shirt, over a shirt and a cardigan, and over a rolled-up sleeve were 128.8 (20.0)/69.3 (13.2), 131.0 (22.2)/73.9 (15.2), 136.9 (22.2)/78.9 (15.8), and 136.4 (26.0)/80.7 (15.9) mmHg, respectively. BP measurements over clothed arms were significantly higher than bare arm measurements. BP differences were significant when measured over a cardigan after adjusting for sex and treatments for hypertension. CONCLUSION: In the elderly, clothing has a significant effect on BP measurements. The arms should be undressed as much as possible for BP measurements in the elderly.


Asunto(s)
Brazo , Determinación de la Presión Sanguínea/métodos , Presión Sanguínea , Anciano Frágil , Anciano , Anciano de 80 o más Años , Brazo/fisiología , Vestuario , Estudios Transversales , Femenino , Humanos , Hipertensión/diagnóstico , Hipertensión/epidemiología , Hipertensión/fisiopatología , Japón/epidemiología , Masculino
6.
Tohoku J Exp Med ; 242(2): 157-163, 2017 06.
Artículo en Inglés | MEDLINE | ID: mdl-28637993

RESUMEN

Alcohol-related injuries in college students are a major public health problem worldwide. We clarified the association between excessive drinking and alcohol-related injuries in Japanese college students. This was a cross-sectional study with a self-administered questionnaire. From January to March 2013, we sampled all college students and graduate students aged 20 years or older during annual health examinations at three colleges in Mie Prefecture in Japan. The questionnaire assessed the frequency of alcohol drinking, amount of alcohol consumed per day, binge drinking during the past year, alcohol-related injuries during the past year, and demographic data. Logistic regression analysis was conducted on the association between excessive alcohol use and alcohol-related injuries. A total of 2,842 students underwent health examinations, of whom 2,177 (76.6%) completed the questionnaire. Subjects included 1,219 men (56.0%) and 958 women (44.0%). Eighty-eight men (7.2%) and 93 women (9.7%) were classified as excessive weekly drinkers, while 693 men (56.8%) and 458 women (47.8%) were determined to be binge drinkers. Eighty-one men (6.6%) and 26 women (2.7%) had experienced alcohol-related injuries during the past year. In the logistic regression analysis, binge drinkers (odds ratio 25.6 [8.05-81.4]) and excessive weekly drinkers (odds ratio 3.83 [2.41-6.09]) had a history of significantly more alcohol-related injuries, even after adjusting for age and sex. In conclusion, alcohol-related injuries in college students in Japan were strongly associated with excessive drinking. As a strategy for preventing such injuries in this population, an interventional study is required to identify effective methods for reducing excessive alcohol use.


Asunto(s)
Consumo de Bebidas Alcohólicas/efectos adversos , Consumo de Bebidas Alcohólicas/epidemiología , Estudiantes/estadística & datos numéricos , Universidades/estadística & datos numéricos , Heridas y Traumatismos/epidemiología , Heridas y Traumatismos/etiología , Borrachera/epidemiología , Estudios Transversales , Femenino , Humanos , Japón/epidemiología , Modelos Logísticos , Masculino , Análisis Multivariante , Adulto Joven
7.
Fam Pract ; 33(5): 517-22, 2016 10.
Artículo en Inglés | MEDLINE | ID: mdl-27402639

RESUMEN

BACKGROUND: Although guidelines recommend that blood pressure (BP) should be measured on a bare arm, BP is sometimes measured over clothing in clinical settings. OBJECTIVE: To assess the accuracy of BP measurements over clothing rolled up to the elbow in clinical settings. METHODS: This was a cross-sectional study to a total of 186 individuals recruited from a primary care clinic and two day-care facilities between July and September 2014. Main outcome measures were BP measurements on (i) a bare arm, (ii) over the sleeve of a cardigan and (iii) over the sleeve of a cardigan rolled up to the elbow. BP was compared across measurement conditions using the paired t-test and multiple analysis of variance adjusting for age, sex, measurement order and interaction between clothing condition and measurement order. RESULTS: Of 186 subjects, 38.5% were male. Mean age was 74.6 years. Mean BP with a bare arm, over a sleeve and over a rolled-up sleeve was 128.9 (SD 19.1)/67.4 (10.8) mmHg, 132.8 (21.0)/72.6 (11.5) mmHg and 133.4 (21.3)/74.4 (12.1) mmHg, respectively. There were significant differences in BP between the bare arm and over a cardigan sleeve (P < 0.001) and the bare arm and over a rolled-up cardigan sleeve (P < 0.001). BP differences were significant even after adjusting for age group, sex, measurement order and interaction between clothing condition and measurement order. CONCLUSIONS: Although previous studies have suggested BP measurements over clothing are acceptable, our results suggest that BP should be measured on bare arms as recommended by guidelines whenever feasible.


Asunto(s)
Determinación de la Presión Sanguínea/métodos , Presión Sanguínea , Hipertensión/diagnóstico , Anciano , Anciano de 80 o más Años , Vestuario , Estudios Transversales , Medicina Familiar y Comunitaria , Femenino , Adhesión a Directriz , Humanos , Japón , Masculino , Persona de Mediana Edad , Análisis Multivariante , Análisis de Regresión
8.
Asia Pac Fam Med ; 14(1): 3, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-25883530

RESUMEN

BACKGROUND: Many medical students in Japan were brought up in urban areas, thus rural medical practice is often unfamiliar to them. The University of Tsukuba created a one-day early_exposure program to provide freshman students with experience in rural practices. This study was designed to clarify how this one-day early_exposure program affected medical students' attitudes toward and knowledge of rural practices. FINDINGS: First-year medical students (n = 103) were assigned to one of seven rural clinics in which they experienced rural practice for one day. A pre- and post-program questionnaire, rated on a 5-point Likert scale, was administered to assess students' interest in and knowledge of rural medical practice, with higher scores indicating greater interest and knowledge. Respondents who gave answers of 4 or 5 were defined as having high interest and knowledge. One hundred and one (98.1%) responses were received from students. After the program, the percentage of students interested in rural medical practices was increased (pre- and post-program: 39.0% and 61.0%, respectively; P < .001), as was the number of students who wanted to become physicians in a rural medical practice (pre- and post-program: 53.0% and 73.0%, respectively; P < .01). CONCLUSIONS: Our one-day early_exposure program demonstrated a positive impact on medical students' interest in and knowledge of rural medical practice. Further follow-up surveys are needed to clarify whether these effects are sustained long-term.

9.
Am J Hosp Palliat Care ; 31(7): 699-709, 2014 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-24113194

RESUMEN

To clarify physicians' practices and attitudes regarding advance care planning (ACP) in palliative care units (PCUs) in Japan, we conducted a self-completed questionnaire survey of 203 certificated PCUs in 2010. Ninety-nine physicians participated in the survey. Although most Japanese palliative care physicians recognized the importance of ACP, many failed to implement aspects of patient-directed ACP that they acknowledged to be important, such as recommending completion of advance directives (ADs), designation of health care proxies, and implementing existing ADs. The physicians' general preference for family-centered decision making and their feelings of difficulty and low confidence regarding ACP most likely underlie these results. The discrepancy between physicians' practices and their recognition of the importance of ACP suggests an opportunity to improve end-of-life care.


Asunto(s)
Planificación Anticipada de Atención , Directivas Anticipadas/psicología , Directivas Anticipadas/estadística & datos numéricos , Cuidados Paliativos al Final de la Vida/psicología , Cuidados Paliativos/psicología , Médicos/psicología , Cuidado Terminal/psicología , Adulto , Anciano , Anciano de 80 o más Años , Actitud del Personal de Salud , Toma de Decisiones , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Japón , Masculino , Persona de Mediana Edad , Relaciones Médico-Paciente , Encuestas y Cuestionarios , Adulto Joven
10.
BMC Med Educ ; 13: 74, 2013 May 24.
Artículo en Inglés | MEDLINE | ID: mdl-23706105

RESUMEN

BACKGROUND: Clinical skills tests have been added to the national medical licensure examinations in Canada, the U.S., Korea and Switzerland. Adding a clinical skills test to the Japanese national medical licensure examination should also be considered under the Medical Practitioners Act. On the other hand, such tests might be costly and represent an economic burden to the nation's citizens. Thus, it is appropriate to obtain the opinion of the general public for the introduction of such tests. Although a clinical skills test can measure various competencies, it remains uncertain as to what should be measured. In this study, we aimed to ascertain public opinion regarding the clinical skills demanded of novice physicians. METHODS: We conducted an internet-based survey of the general public in Japan. We randomly selected 7,213 people aged 20 to 69 years. The main topics surveyed included: whether the Japanese government should add a skills test to the existing national medical licensure examination; what kind of skills should be included in this test; and who should pay for the examination. RESULTS: Of 3,093 (1,531 men and 1,562 women) people who completed the questionnaire (completion rate 42.9%), 90.5% (n = 2,800) responded that a clinical skills test should be part of the national medical licensure examination. The main skills which respondents thought should be included were "explaining and discussing medical issues in an appropriate manner to patients" (n = 2,176, 70.4%), "accurately diagnosing problems by conducting a physical examination" (n = 1,984, 64.1%), and "carefully interviewing patients to make a diagnosis" (n = 1,663; 53.8%). Three-fifths of the respondents (n = 1,900; 61.4%) responded that more than half of the cost of the examination should be paid by the Japanese government. CONCLUSIONS: The majority of respondents indicated that a clinical skills test should be added to the national medical licensure examination. These respondents who represent the general public were requesting the verification of communication, diagnostic interview and diagnostic physical examination skills. Medical educators should incorporate these public requests, and teach and assess medical students accordingly.


Asunto(s)
Competencia Clínica/estadística & datos numéricos , Evaluación Educacional , Médicos/normas , Adulto , Anciano , Actitud Frente a la Salud , Competencia Clínica/normas , Recolección de Datos , Diagnóstico , Evaluación Educacional/normas , Femenino , Humanos , Internet , Japón/epidemiología , Licencia Médica/normas , Masculino , Persona de Mediana Edad , Examen Físico/normas , Relaciones Médico-Paciente , Encuestas y Cuestionarios , Adulto Joven
12.
Nihon Koshu Eisei Zasshi ; 51(9): 798-805, 2004 Sep.
Artículo en Japonés | MEDLINE | ID: mdl-15526763

RESUMEN

OBJECTIVES: This study was conducted to investigate the association between municipality expectations of retaining physicians in public medical facilities and their evaluation of the physicians from key aspects considered important for practicing community medicine. METHODS: A cross-sectional study using a self-reported postal questionnaire survey was conducted with all 3,152 local governments in Japan from July to September, 2000. Three thousand and fifty-nine (94%) local governments responded. Of the responders, 1,315 (42%) operated public medical facilities. These local governments evaluated their expectations of retaining physicians in medical facilities and the physicians themselves focusing on the following aspects considered important for practicing community medicine: degree of government satisfaction with the physician's involvement in public health and welfare services; primary care for emergency patients; human relationships between the physician and the population, staff of the facility or the municipal officials; public estimation of the facility; income and expenditure of the facility; understanding of the local government's system. RESULTS: The subjects were 1,092 local governments (83.0%) that responded to all of the questions. The proportion of municipalities expecting to retain physicians was 56% overall, 61% in rural areas and 44% in urban areas (P<0.001). The proportion of governments satisfied with the physicians' human relationships was higher than the other factors and the proportion satisfied about income and expenditure of facilities was the lowest. Multiple logistic regression analysis revealed that the degree of local government expectation of retaining physicians was significantly associated with the physicians' involvement in public health and welfare services (Odds ratio (OR) 1.8; 95% confidential interval (95%CI) 1.3-2.5), their human relationship with the population and public estimation of facilities (OR 1.6; 95%CI 1.1-2.2), and income and expenditure (OR 1.3; 95%CI 1.01-1.8 in all, OR 1.7; 95%CI 1.7-2.4 in rural areas). Primary care for emergency patients demonstrated a significant association in rural areas (OR 1.6; 95%CI 1.1-2.3). CONCLUSIONS: Municipal expectation of retaining physicians in public medical facilities was significantly associated with factors related to the integration of medical, public health and welfare systems, human relationship with the population, public estimation and income and expenditure of the facilities overall. In rural areas, there was a closer association with income and expenditure and a significant association with emergency care. These findings suggest that the local governments' thought related with the expectation of retaining physicians are influenced by their different needs for medical services in community healthcare.


Asunto(s)
Servicios de Salud Comunitaria , Gobierno Local , Médicos/provisión & distribución , Estudios Transversales , Renta , Japón , Reorganización del Personal , Médicos/tendencias , Administración en Salud Pública/tendencias , Encuestas y Cuestionarios , Recursos Humanos
13.
Nihon Koshu Eisei Zasshi ; 51(1): 30-9, 2004 Jan.
Artículo en Japonés | MEDLINE | ID: mdl-14994503

RESUMEN

OBJECTIVES: In order to practice appropriate community healthcare activities, it is essential for healthcare providers to integrate medical, public health, and welfare systems into one comprehensive healthcare body. In Japan, local governments are obliged to provide their entire population with public health and welfare services And physicians who work as government employees at public medical facilities play an important role in combining the three systems. It has been reported that the level of subjective evaluation by the municipality of the degree of involvement by physicians in the region's public health activities and welfare services is associated with the standardized mortality rates for strokes in the area's population. However, little is known about which specific public health and welfare services are more important as factors contributing to the level of evaluation of physicians by the people or municipality. The present study was therefore conducted to determine associations between levels of participation by community physicians in each specific public health or welfare service and the respective levels of evaluation by their municipalities. METHODS: A cross-sectional study design using a self-reported postal questionnaire survey was conducted with all 3,152 local governments in Japan from July to September, 2000. A total of 3,059 local governments (94%) responded, and 1,315 (42%) that operated a public medical facility were analyzed. The aspects from which local governments evaluated the physicians working for their public medical facilities were: the frequency of involvement in each of 13 services related to public health and welfare; the degree of satisfaction of governments with the physicians' involvement in each of the services; and the relationship between the physicians and the municipal healthcare officials. RESULTS: The services in which the local governments responded that they 'always' appreciated the physicians involved was significantly associated with the degree of municipal satisfaction. In the multiple logistic regression analysis, the degree of municipal satisfaction was significantly associated with their perception of consistent involvement by the physicians in case conferences on homecare management, health counseling, health education, life style instruction after basic health screening (odds ratio > 2.0 respectively), and school healthcare, vaccination, school health screening, and basic health screening (0 < odds ratio < 1.5 respectively). There was no significant difference in the level of satisfaction between large and small municipalities. CONCLUSIONS: The findings showed that high levels of municipal appreciation of consistent participation by physicians in certain public health and welfare services is associated with a higher degree of local government satisfaction with the physicians. It is noteworthy that services found to be highly associated with municipal satisfaction were concerned with individual affairs or education, and with activities that do not entail any legal obligation.


Asunto(s)
Servicios de Salud Comunitaria/normas , Médicos , Instalaciones Públicas , Ciudades , Estudios de Evaluación como Asunto , Humanos , Gobierno Local , Administración en Salud Pública , Bienestar Social , Encuestas y Cuestionarios
14.
Nihon Ronen Igakkai Zasshi ; 40(6): 627-32, 2003 Nov.
Artículo en Japonés | MEDLINE | ID: mdl-14689856

RESUMEN

To elucidate the present condition about health, medicine and welfare, and to evaluate factors associated with relief for elderly life in each community, a questionnaire survey was conducted among officers of all the municipalities in Japan. We asked officers about their recognition whether older people can live feeling relieved or not, and other factors about health, medicine and welfare condition in each municipality. Demographic data of each municipality were also used as dependent variables. Odds ratios and their 95% confidence intervals for the officers' evaluation of relief for life of the elderly were calculated using unconditional logistic models. Of the 3.252 municipalities, 3,059 (94%) responded to the survey. Of the respondents, 2,957 municipalities (91%) answered questions about relief for elderly life. "Receiving satisfactory medical home care service", "cooperative function between medicine, health, and welfare sections", and "receiving complete welfare service" were associated with their recognition about relief for elderly life in both of cities and rural towns. In addition, "the rate of elderly households" and "the easiness to maintain nursing staff" were associated in the cities. This study indicated that more arrangements are needed not only about health and welfare aspects, but also about medical service, especially medical home care service systems to support older peoples' life in the community.


Asunto(s)
Anciano , Necesidades y Demandas de Servicios de Salud/tendencias , Servicios de Salud para Ancianos/tendencias , Bienestar Social/tendencias , Estudios Transversales , Encuestas de Atención de la Salud , Humanos , Japón , Servicios de Salud Rural/tendencias , Encuestas y Cuestionarios , Servicios Urbanos de Salud/tendencias
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