Community-based Medicine Research Articles

Comparison of attitudes toward community-based medicine between regional-quota and general-selected medical student in Japan.

Objective: This study compared the regional-quota and general-selected medical students' understanding, interest, and confidence in the community medicine practice and their attitudes toward the concept guidelines. Methods: We conducted a Web-based questionnaire survey regarding the understanding, interest, and confidence in future community medicine practice and attitudes toward concept guidelines among medical students of all grades (regional-quota and general-selected: n=82 and n=617, respectively). Results: The overall response rates were 68.5% (56/82) and 66.0% (409/617) in the regional-quota and general-selected groups, respectively. Although there was no significant difference between the groups in terms of understanding (P=0.998), interest and confidence in future practice were significantly higher in the regional-quota group (both P<0.001). There was no significant difference between the two groups for any of the six questions regarding community medicine guidelines. Conclusion: The understanding of community medicine or its conceptual guidelines did not significantly differ between the two groups; however, interest and confidence in future practice were significantly higher in the regional-quota group. These results suggest that the regional-quota system positively upregulates the interest in community medicine, which could be associated with confidence in future practice. Comprehensive and longitudinal improvements in the regional-quota system may be effective in cultivating community medicine.

The Role of Problem-Based Learning in Preparing Medical Students to Work As Community Service-Oriented Primary Care Physicians: A Systematic Literature Review.

The number of primary care physicians in the United States is dwindling rapidly, and osteopathic medical schools are embracing the challenge of leading students toward a career in primary care to meet this need. In recent years, the Problem-Based Learning (PBL) curriculum in medical education has emerged as a patient-centered, social-justice-focused methodology. The unique format of PBL centered around patient cases allows learning through community-based medicine, promoting medical graduates' entry into primary care. Through exploring the literature on this topic, the research question posed for this review is as follows: How have the skills gained in PBL been effectively preparing medical students to become community service-oriented primary care physicians, and how can we qualitatively and quantitatively assess a learner's preparedness to engage in primary care work? The variables studied were board licensing examination scores, clinical competence, and interpersonal skills, all of which emerged as common ways to assess learners' preparedness to work in primary care. The methodology of this literature review was organized using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart to describe how articles were selected and synthesized to evaluate the variables. The results revealed the variables to be consistent strengths of PBL students, particularly clinical competence, and interpersonal skills, both of which are key in working in primary care and any clinical specialty. Since early in its implementation, literature has demonstrated the tendencies of PBL students to be interested in and later work in primary care, though little follow-up has been done recently. The question of why this phenomenon exists was largely answered by our literature review. In conclusion, through our analysis of the existing literature, the authors demonstrated that the PBL curriculum helps foster students' desire to serve patients. Limitations of the literature included small sample sizes, heterogeneous analysis methods, limited inclusion of qualitative assessment of student progress, and limited existing data on the prevalence of PBL in medical schools, as well as the entrance of PBL graduates into primary care careers.

Data Analysis of Physician Competence Research Trend: Social Network Analysis and Topic Modeling Approach.

Studies on competency in medical education often explore the acquisition, performance, and evaluation of particular skills, knowledge, or behaviors that constitute physician competency. As physician competency reflects social demands according to changes in the medical environment, analyzing the research trends of physician competency by period is necessary to derive major research topics for future studies. Therefore, a more macroscopic method is required to analyze the core competencies of physicians in this era. This study aimed to analyze research trends related to physicians' competency in reflecting social needs according to changes in the medical environment. We used topic modeling to identify potential research topics by analyzing data from studies related to physician competency published between 2011 and 2020. We preprocessed 1354 articles and extracted 272 keywords. The terms that appeared most frequently in the research related to physician competency since 2010 were knowledge, hospital, family, job, guidelines, management, and communication. The terms that appeared in most studies were education, model, knowledge, and hospital. Topic modeling revealed that the main topics about physician competency included Evidence-based clinical practice, Community-based healthcare, Patient care, Career and self-management, Continuous professional development, and Communication and cooperation. We divided the studies into 4 periods (2011-2013, 2014-2016, 2017-2019, and 2020-2021) and performed a linear regression analysis. The results showed a change in topics by period. The hot topics that have shown increased interest among scholars over time include Community-based healthcare, Career and self-management, and Continuous professional development. On the basis of the analysis of research trends, it is predicted that physician professionalism and community-based medicine will continue to be studied in future studies on physician competency.

Association between Undergraduate Education for Community-Based Medicine and General Practice Majors: A Longitudinal Study in Japan.

There is a shortage of general practitioners in Japan. With the revision of educational guidelines, general practice (GP) education has improved. However, the amount of education on GP in medical schools remains inconsistent. This study examined the relationship between medical students' amount of GP-related education and their subsequent choice of GP majors. A retrospective cohort study was conducted in a teaching hospital in Japan. Participants were residents in the hospital. The exposure comprised compulsory lectures and training time for community-based medicine in medical schools. The outcome included participants choosing GP majors after their initial 2-year junior residency. Fifty-one participants were included in the final analysis. Of these, 14 majored in GP and 37 in non-GP after their initial 2-year junior residency. Of the participants who took GP lectures for 18 hours or more, 11 chose GP majors, and 18 chose non-GP majors (risk ratio, 2.78; 95% confidence interval [CI], 0.88-8.79). Of the participants who underwent training for 12 days or more, 10 chose GP majors, and 16 chose non-GP majors (risk ratio, 2.40; 95% CI, 0.87-6.68). The results do not support the association between the amount of compulsory undergraduate education for community-based medicine and the subsequent increase in the number of residents choosing GP majors in Japan. Educators would do well to explore different approaches, such as improving the quality of education to increase the number of GP residents. Further research is needed to reach more definitive conclusions.

It\u2019s how we practice that matters: professional identity formation and legitimate peripheral participation in medical students: a qualitative study

BackgroundThe process of Legitimate Peripheral Participation (LPP) within a community of practice framework (CoP) was used to explore graduate entry medical students’ professional identity formation (PIF) during their first year of study. A conceptual model has been developed that can be used by medical educators to better understand PIF and to aid the explicit incorporation of PIF activity within the undergraduate curriculum.MethodsTen students from one UK medical school participated in the longitudinal study and were interviewed at three points during the first year. Semi-structured group interviews were used to explore students’ experience of the clinical environment and the nature of their interactions with both clinicians and patients in a community-based medicine practice. The interviews were audio recorded and transcribed. Thematic analysis was used to identify overarching themes which are represented as facets in the model of PIF.ResultsResults demonstrate that students are legitimately peripherally participating within both medical student CoPs and wider medical CoPs. Themes identified within the narratives have allowed the development of a new model to understand PIF within the context of LPP in a CoP. This has five facets: Awareness, Collaboration, Negotiation, Evaluation and Realisation. Sophisticated reflection-in-action is shown to be an important aspect of PIF and enables a more conscious understanding of the change that is occurring in our students.ConclusionPIF is a complex, non-linear process that is supported by reflection-in-action and early student introduction to clinical practice. It can be recognised in students’ narratives in their changing use of language, their understanding of the medical COP, and their evolving relational participation with those around them. This study adds to those that have previously explored PIF. The model of PIF developed in this study illustrates how experiences in the clinical environment support PIF. Medical educators may find this model helpful when considering how PIF can be explicitly encouraged in the medical curriculum and how reflection may be used for the purpose of identity change.

COVID-19 may exacerbate the clinical, structural and psychological barriers to retention in care among women living with HIV in rural and peri-urban settings in Uganda

BackgroundRetention of pregnant and breastfeeding women and their infants in HIV care still remains low in Uganda. Recent literature has shown that the effects of COVID-19 mitigation measures may increase disease burden of common illnesses including HIV, Tuberculosis, Malaria and other key public health outcomes such as maternal mortality. A research program was undertaken to locate disengaged HIV positive women on option B+ and supported them to reengage in care. A 1 year follow up done following the tracing revealed that some women still disengaged from care. We aimed to establish the barriers to and facilitators for reengagement in care among previously traced women on option B+, and how these could have been impacted by the COVID-19 pandemic.MethodsThis was a cross sectional qualitative study using individual interviews conducted in June and July, 2020, a period when the COVID-19 response measures such as lockdown and restrictions on transport were being observed in Uganda. Study participants were drawn from nine peri-urban and rural public healthcare facilities. Purposive sampling was used to select women still engaged in and those who disengaged from care approximately after 1 year since they were last contacted. Seventeen participants were included. Data was analysed using the content analysis approach.ResultsWomen reported various barriers that affected their reengagement and retention in care during the COVID-19 pandemic. These included structural barriers such as transport difficulties and financial constraints; clinical barriers which included unsupportive healthcare workers, short supply of drugs, clinic delays, lack of privacy and medicine side effects; and psychosocial barriers such as perceived or experienced stigma and non-disclosure of HIV sero-status. Supportive structures such as family, community-based medicine distribution models, and a friendly healthcare environment were key facilitators to retention in care among this group. The COVID-19 pandemic was reported to exacerbate the barriers to retention in care.ConclusionsCOVID-19 may exacerbate barriers to retention in HIV care among those who have experienced previous disengagement. We recommend community-based models such as drop out centres, peer facilitated distribution and community outreaches as alternative measures for access to ART during the COVID-19 pandemic.

Development and validation of resource-driven risk prediction models for incident chronic kidney disease in type 2 diabetes

Prediction models for population-based screening need, for global usage, to be resource-driven, involving predictors that are affordably resourced. Here, we report the development and validation of three resource-driven risk models to identify people with type 2 diabetes (T2DM) at risk of stage 3 CKD defined by a decline in estimated glomerular filtration rate (eGFR) to below 60 mL/min/1.73m2. The observational study cohort used for model development consisted of data from a primary care dataset of 20,510 multi-ethnic individuals with T2DM from London, UK (2007–2018). Discrimination and calibration of the resulting prediction models developed using cox regression were assessed using the c-statistic and calibration slope, respectively. Models were internally validated using tenfold cross-validation and externally validated on 13,346 primary care individuals from Wales, UK. The simplest model was simplified into a risk score to enable implementation in community-based medicine. The derived full model included demographic, laboratory parameters, medication-use, cardiovascular disease history (CVD) and sight threatening retinopathy status (STDR). Two less resource-intense models were developed by excluding CVD and STDR in the second model and HbA1c and HDL in the third model. All three 5-year risk models had good internal discrimination and calibration (optimism adjusted C-statistics were each 0.85 and calibration slopes 0.999–1.002). In Wales, models achieved excellent discrimination(c-statistics ranged 0.82–0.83). Calibration slopes at 5-years suggested models over-predicted risks, however were successfully updated to accommodate reduced incidence of stage 3 CKD in Wales, which improved their alignment with the observed rates in Wales (E/O ratios near to 1). The risk score demonstrated similar model performance compared to direct evaluation of the cox model. These resource-driven risk prediction models may enable universal screening for Stage 3 CKD to enable targeted early optimisation of risk factors for CKD.

907-P: Diabetes-Inspired Culinary Education (DICE): An Innovative Approach to Type 1 Diabetes Management through Culinary Medicine

Despite the critical role nutrition plays in T1DM management and growth/development, youth with TIDM consistently have poorer diet qualities compared with their healthy counterparts. While culinary medicine is an area of research that is still in its infancy, initial studies have demonstrated success in improving youth diet quality and dietary and disease management outcomes in individuals with T2DM. Yet despite its great potential to elicit positive behavior change among youth with T1DM, this area of research is under-explored. Therefore, Diabetes Inspired Culinary Education (DICE), a community-based culinary medicine program aiming to improve diet quality and disease management among 6-14 year old youth with T1DM, was developed and assessed for feasibility and potential efficacy in a pilot study. The DICE program included ten, 90-minute lessons delivered weekly at a community teaching kitchen and included: hands-on, age-appropriate culinary education; nutrition and diabetes education delivered through experiential learning; a group family meal prepared by participating youth; and culinary/mealtime goal-setting. Baseline and post-test outcomes were assessed on participating families at the child- (food preparation self-efficacy (SE), involvement, attitude; dietary intake; diabetes management; diabetes quality of life; hgbA1c; BMI), primary caregiver- (dietary intake; diabetes management SE; mealtime SE; BMI) and family-level (family food preparation; mealtime environment). Feasibility was evaluated using participant attendance, retention and a program-specific fidelity tool. Eleven families were recruited and 8 completed (73% retention) the program. On average, 78% of participating families attended weekly lessons. Improvements in primary caregiver SE for healthy mealtime behaviors (p=0.02) and family food preparation (p=0.05) were observed at post-test, inferring potential program efficacy. Disclosure C. R. Mcmanus: None. H. Barkoukis: None. R. Kim: None. J. Nguyen: None.

Development of Community-based Medicine, Considering Residents as Healthcare Resource

Development of Community-based Medicine, Considering Residents as Healthcare Resource

Cuba’s response to COVID-19: lessons for the future

Purpose The purpose of this paper is to examine the relevance of Cuba’s medical system, its health tourism and related diplomacy in the context of the recent COVID-19 pandemic for the global response to disease outbreaks. In addition to Cuba being a destination for leisure tourists in the Caribbean, the renowned Cuban medical system attracts thousands of health tourists seeking low-cost but high-quality treatment. This paper demonstrates how Cuba’s unique response to the pandemic, which included sending thousands of medical staff abroad, can inform structural and global issues and contribute to a more sustainable future. Design/methodology/approach The research in this study is primarily drawn from published academic and media sources that address Cuba’s medical system, its health tourism and the government’s response to the recent pandemic. The author, a political scientist and an author of many publications on Cuba, and the PI of a study focused on Cuban tourism, will also draw on her expertise. Findings This paper addresses the Cuban Government’s ongoing response to the COVID-19 pandemic and places this response in the context of Cuba’s medical system, its health tourism and related diplomacy. It reveals key lessons from Cuba’s response for other tourist destination states and, more broadly, for the worldwide response to global outbreaks and the management of health systems. The findings will further research in diplomacy and tourism as well as inform policy and practice. Research limitations/implications This paper explores an ongoing topic and thus further research will be required following the pandemic. Practical implications This research note offers important implications for practice including providing accurate, research-based information that challenges misinformation about Cuba’s health system, its medical diplomacy program, health tourism and its response to COVID-19. It offers valuable lessons for public health authorities including the importance of preventative health measures, community medicine and the benefits of working globally to combat outbreaks through the sharing of medical staff and resources. Social implications This research note reveals the health, political and social implications of Cuba’s response in this time of crisis. It shows the benefits of a robust but low-cost community-based medicine program, medical diplomacy and how a state’s response during crisis can moderate the global inequities and injustices such as unequal access to care that often accompany disease outbreaks such as COVID-19. Originality/value This research note is an early analysis of a response by an important tourist destination country to the pandemic. The author anticipates that the information provided to the international community via this open access journal will offer practical implications for the ongoing global efforts to manage this crisis and contribute to the research on tourism, diplomacy, justice and health policy.

Third-Year Medical Students' Self-perceived Knowledge About Health Disparities and Community Medicine.

Medical providers' attitudes about caring for vulnerable populations have significant implications for persistent health disparities. Therefore, assessing medical students' self-perceived knowledge about community-based medicine and care for underserved populations can provide insights for improving health care delivery to achieve health equity. We evaluated third-year medical students' perceptions of their knowledge and attitudes about community medicine, and addressing health care needs of vulnerable populations. From October 2, 2017 to July 12, 2019, third-year medical students at a private, urban medical school were asked to complete an assessment survey during their family medicine clerkship orientation. The anonymous survey assessed students' self-perceived knowledge and attitudes regarding community medicine and care of vulnerable populations. We examined differences in survey responses by student demographics. A total of 401 students participated in the survey; 50.5% of respondents agreed that they had knowledge to assess health literacy of the patient, while only 22.2% of students agreed that they had knowledge about how to identify a community and conduct a community health needs assessment. Additionally, students agreed with being most comfortable providing care to adolescents (73.0%) and the elderly (69.5%), and that they were least comfortable caring for incarcerated individuals (31.7%) and immigrants/refugees (44.1%). Assessment of learners' self-perceived knowledge can help highlight areas for educational interventions. Our findings suggest the need for improving medical student knowledge in areas of community health and health care for specific vulnerable populations.

What is Needed in Medical Care in a Super-Aging Society? -From a Community-Based Medicine Perspective-

What is Needed in Medical Care in a Super-Aging Society? -From a Community-Based Medicine Perspective-

Food as Medicine: A Pilot Nutrition and Cooking Curriculum for Children of Participants in a Community-Based Culinary Medicine Class.

Healthy dietary change proves challenging for all families navigating the variable food preferences of children but can be especially burdensome for low-income families with limited resources. Encouragingly, programs that engage children in hands-on nutrition education appear to promote changes that positively impact the entire family. From these observations, we designed a dedicated pediatric cooking and nutrition class concurrent with a community-based culinary medicine class for adult clients of a food pantry. Through the Food As Medicine (FAME) nutrition education initiative at community pantry sites, we launched culinary medicine classes for pantry clients and offered concurrent culinary medicine classes for their children. Each pediatric class included an interactive lesson, hands-on cooking, and crafts or games to reinforce concepts prior to sharing a meal with parents. The pilot classes launched at two pantry sites, and the team leading the pediatric classes solicited feedback from participants and stakeholders to enable thematic analysis of the impact. Observations included the ability of children to identify new foods and to report enthusiasm for assisting with food preparation at home. Child participants engaged in the class demonstrated willingness to try new foods when joining their parents for a meal. This pilot intervention details an educational, hands-on nutrition and cooking curriculum for children of low-income families. Through age-appropriate experiential learning, we observed a positive impact of this class in its ability to encourage family participation, to augment nutrition lessons taught to parent participants, and to empower young learners to advocate for healthy dietary change.

Motherhood and medicine: systematic review of the experiences of mothers who are doctors.

To synthesise what is known about women combining motherhood and a career in medicine by examining the published research into their experiences and perspectives. We reviewed peer-reviewed articles published or available in English reporting original research into motherhood and medicine and published during 2008-2019. Two researchers screened each abstract and independently reviewed full text articles. Study quality was assessed. CINAHL, MEDLINE, PsycINFO, Web of Science, and Scopus abstract databases. The database search identified 4200 articles; after screening and full text assessment, we undertook an integrative review synthesis of the 35 articles that met our inclusion criteria. Three core themes were identified: Motherhood: the impact of being a doctor on raising children; Medicine: the impact of being a mother on a medical career; and Combining motherhood and medicine: strategies and policies. Several structural and attitudinal barriers to women pursuing both medical careers and motherhood were identified. It was often reported that women prioritise career advancement by delaying starting a family, and that female doctors believed that career progression would be slowed by motherhood. Few evaluations of policies for supporting pregnant doctors, providing maternity leave, and assisting their return to work after giving birth have been published. We did not find any relevant studies undertaken in Australia or New Zealand, nor any studies with a focus on community-based medicine or intervention studies. Prospective investigations and rigorous evaluations of policies and support mechanisms in different medical specialties would be appropriate. PROSPERO CRD42019116228.

Experiencing and designing community-based medicine - development and evaluation of an elective based on explorative learning.

Objective: To develop and evaluate an elective for the 6th semester in the medical curriculum at Charité – Universitätsmedizin Berlin. In this elective, medical students could experience and test Community Oriented Primary Care, hence the integration of public health into primary care, by using explorative learning methods.Method: In three consecutive semester, all participants of the elective filled in a questionnaire before and after the elective. The self-developed questionnaire covered socio-demographic features, an evaluation of the elective as well as a self-assessment regarding learning objectives and attitudes. The results were analyzed descriptively; the learning success was measured by mixed model regression.Results: Thirty-one students (100% of the elective participants) took part in the evaluation, 30 of them (96.8%) at both survey dates. The students evaluated the elective and particularly the commitment of the teachers as very positive. The five-level Likert scale showed a significant growth of knowledge by an average of 1.3 points. The attitudes of the students hardly changed.Conclusion: Students can experience Public Health practically by means of Community Oriented Primary Care. In doing so, explorative learning is an appropriate method providing a significant increase in competences.

4) Case Summary for Community-based Medicine

4) Case Summary for Community-based Medicine

シリーズ : 初期臨床研修と医学教育 (第5回) 地域医療現場からみた卒後臨床研修

シリーズ : 初期臨床研修と医学教育 (第5回) 地域医療現場からみた卒後臨床研修

From Patients to Populations: Rhetorical Considerations for a Post-Compliance Medicine

Scholars have criticized the rhetoric of compliance for decades. For example, they have offered a more nuanced account of why patients are “noncompliant,” recasting noncompliance itself as rational behavior. While these insights made important strides toward the larger goal of disrupting power dynamics within medical encounters, and while they yielded new rhetorical inventions such as adherence and concordance, these new terms retained many of compliance’s problematic features. Building on the work of rhetoricians of health and medicine and other scholars, we cast compliance’s persistence as a symptom of shortcomings in the dominant medical model and its tendency to discipline individual patients instead of work with communities to facilitate health. We argue that this model is being challenged in especially dramatic ways with the increased focus on populations and communities. Drawing on the work of Michel Foucault to understand how to navigate problems associated with the disciplinary approach, the authors argue not just for a better understanding of the causes of noncompliance, but for a post-compliance conception of medicine. Among other things, such a view of medicine will require new rhetorical structures that can better support the aims of population health and community-based medicine.

Occurrence of Chronic Stage Chikungunya in the General Population of Martinique during the First 2014 Epidemic: A Prospective Epidemiological Study.

Chronic stage chikungunya (CHIK), defined by persisting symptoms more than 3 months after initial diagnosis of acute infection, is frequent. However, its burden and impact have rarely been described prospectively in a general population during an ongoing epidemic in the Caribbean. From January 2014 to January 2015, a severe CHIK outbreak occurred in Martinique. Our objective was to describe epidemiological characteristics and outcomes of chronic stage CHIK in its local population. Participants, clinically diagnosed with probable CHIK infection, were included prospectively by general practitioners during the epidemic's peak from April to October 2014. All identified cases benefited from a follow-up phone call 3 months or more after initial diagnosis during which they were interrogated about persisting clinical signs, past and ongoing treatment, and quality of life. Five hundred and nine subjects participated in the study. Mean age at initial diagnosis was 43.2 ± 23.6 years with a female-male ratio of 1.98. Two hundred participants (39.3%) had probable chronic stage CHIK: 98.5% still experienced pain at least 3 months after acute infection, with 84.3% of reported joint pains; 21.2% were woken up by the pain; 47.2% felt depressed/anxious; and 31.3% experienced memory/concentration disorders. Resumption of daily activity and work was complicated for 55.8% and 36.2% of cases. Persistent impact on morbidity, health outcomes, psychological, and economic aspects further underline the crucial role of community-based medicine and the necessity of an evidence-based multidisciplinary approach toward chronic stage CHIK identification, management, and follow-up in this particular world region.

Effect of Helicobacter pylori eradication on elder cases: Observational study in community-based medicine.

AIMTo examine the effect of Helicobacter pylori (H. pylori) eradication therapy on the extra-gastrointestinal factors in elderly patients by a before-after observational study in community medicine.METHODSMedical records (1 May 2013-31 January 2014) of 130 patients who underwent H. pylori eradication therapy with 2-year after-eradication observation in our institute were reviewed. Data on sex; age; body weight; body mass index (BMI); mean corpuscular volume (MCV); total protein; low-density lipoprotein cholesterol, triglyceride, haemoglobin A1c and haemoglobin levels and gastric hyperplastic polyps (GHPs) at eradication was extracted. Two-year after-eradication change in data was analysed by paired-sample t-test; relationship between GHPs and subclinical iron deficiency anaemia (IDA) improvement was evaluated.RESULTSThe mean patient age (median, interquartile range) at eradication was 69.6 (71.5, 64-77) years. Paired-sample t-tests showed that body weight, BMI and MCV increased by 0.52 kg (P = 0.018), 0.25 kg/m2 (P = 0.006) and 0.83 fL (P < 0.001), respectively. The nonparametric Mann-Whitney test showed no significant difference in the change rate of MCV after eradication between the groups with and without GHPs (P = 0.892).CONCLUSIONH. pylori eradication therapy prevented weight loss and subclinical IDA in elderly individuals. GHPs were not associated with subclinical IDA.