Background: The social determinants of health literature provides one type of framework to address health inequities from the coalface of clinical practice to upstream policy changes. This focus on health equity echoes the underpinning principles of comprehensive primary health care service delivery and the evidence-based health-enhancing role of primary care. Despite this potentially natural intersection between social determinants and primary health care theory, the reality of addressing the broader social determinants through clinical primary care practice remains challenging.


Aims:
1) To present evidence on different frameworks and theories for addressing the social determinants of health within primary health care
2) To present learnings from work as a general practitioner in the resource-challenged and “deep-end” communities on the opportunities to address the wider social determinants of health
3) To discuss and present an opportunity for discussion around the locus of control that primary health care workers have in addressing the social determinants of health

Content:
This clinical practice session will first present an introductory theoretical background on different approaches to addressing SDOH in primary health care including, for example, intersectoral partnerships, social prescribing and political advocacy. It will then discuss several clinical vignettes from work in general practice where there have been successful processes to address a wider social determinant of health. It will end by discussing the challenges to addressing social determinants of health in primary health care, with an appeal for primary health care workforce self-care by recognising the limitations and our locus of control, with an opportunity to discuss this further in the questions.

At the conclusion of my presentation, attendees will take away:
1) That there are effective frameworks to understand the impact of broader societal issues on patient health that have a strong evidence base, which intersect closely with our work in primary health care
2) Practical examples from clinical practice addressing social determinants of health in a cross-cultural, cross-language, "deep end" practice in a remote First Nations community in Australia
3) The challenges of trying to address inequitable social and economic systems can be difficult in primary health care and acknowledging these limitations is important for the sustainability of primary healthcare practitioners

Background
Hypertension management remains suboptimal globally; more than half of patients with hypertension do not achieve their blood pressure (BP) targets. Physician-related barriers play an important role in this. This study aimed to explore the challenges faced by primary care physicians (PCPs) in the management of hypertension.

Methods
This qualitative study involved 17 PCPs across five primary care clinics in Singapore. Individual in-depth interviews were conducted by a trained researcher using a topic guide. Purposive sampling was employed to ensure adequate representation of seniority; recruitment was performed until data saturation was achieved. The audio-recorded interviews were transcribed verbatim and checked independently. The data were managed using NVivo and thematic analysis was conducted.

Results
The interviews revealed several physician-related barriers in hypertension management: uncertainty in diagnosing and managing different hypertension phenotypes; challenges in personalising dietary advice; and reluctance in initiating dual therapy. PCPs struggled in managing diastolic, white coat and refractory hypertension, partly because local clinical practice guidelines (CPGs) lacked information on how to approach these phenotypes. While PCPs were confident in providing general dietary counselling, some faced difficulty in dispensing tailored dietary advice. Despite most guidelines recommending the initiation of dual therapy for patients with high BP, most PCPs were reluctant to do so because they anticipated resistance from patients and it would be difficult to identify the culprit drug should side effects occur.

Conclusion
Despite the presence of CPGs and continuing medical education (CME), PCPs continue to experience challenges in managing hypertension; barriers exist in the diagnosis and management of different BP phenotypes, administration of personalised dietary advice possibly stemming from outdated local CPGs and limited consultation time. CPGs and CME should contain a practical guide on how to: diagnose and manage different hypertension phenotypes; provide tailored dietary advice; and address patients’ and PCPs’ concerns about initiating dual therapy.

1. Primary care physicians (PCPs) face difficulty in diagnosing and managing different hypertension phenotypes, personalising dietary advice and initiating dual therapy concurrently.
2. There is a gap in clinical practice guidelines (CPGs) in providing guidance on these physician-related barriers.
3. Regularly updated CPGs and education with input from PCPs may help to improve hypertension care.

The COVID-19 pandemic not only has a serious impact on daily life, but also affects health seeking behavior. Smokers are a high-risk group for contracting and developing severe COVID-19 disease. This study investigated changes in smoking cessation services in a single medical center before and after the COVID-19 pandemic.

We collected data from the Taiwan Ministry of Health and Welfare Smoking Cessation Service System and compared 3-year periods before and after the start of the COVID-19 pandemic (before: 2017-2019, after: 2020-2022/10). We used Student’s t-test to analyze monthly changes in smoking cessation service volume between the two periods. Chi-square test was used to analyze changes in the proportion of sex and age, 3-month success rate and 6-month success rate. A p value of < 0.05 was considered statistically significant.

Before the pandemic, smoking cessation service volume was 3,287, median age was 49 (range: 18–84) years-old, and 3-month success rate was 35.0%. After the pandemic, smoking cessation service volume was 4,117, median age was 50 (range: 18–84) years, and 3-month success rate was 43.0%. Following the pandemic, number of visits increased by 17.1%, proportion of males increased by 1.9%, proportion of elderly patients increased by 2.4%, and 3-month success rate increased by 8.0%, all with statistical significance (p < 0.05). However, the respective 6-month success rates before and after the pandemic were 38.0% and 38.6%, displaying no statistical significance (p ≥0.05).

The fact that smokers are at high risk of suffering from COVID-19 may provide the motivation and increase willingness for individuals to quit smoking during the pandemic. We recommend everyone to take this opportunity to further promote smoking cessation and reduce the risk of COVID-19 infection and complications.

1. Smokers are a high-risk group for contracting and developing severe COVID-19 disease. 2. smokers are at high risk of suffering from COVID-19 may provide the motivation and increase willingness for individuals to quit smoking during the pandemic. 3. Further promote smoking cessation and reduce the risk of COVID-19 infection and complications.

The Remote and Rural Healthcare Education Alliance (RRHEAL) and the Scottish Rural Medicine Collaborative (SRMC) initiated a programme of work across Scottish Remote, Rural and Island Boards to develop a new multidisciplinary Rural Advanced Practitioner (RAP) education pathway. In Scotland some twenty percent of the population live in remote or rural areas spread across ninety-four percent of the land mass. Offering health & social care education in remote, rural or island environments leads to increased retention of those professionals. There is global recognition that Higher Education institutions need to ensure that educational programmes meet the needs of the population, delivering evidence based, socially accountable health education.


RRHEAL in partnership with SRMC, facilitated monthly meetings to involve stakeholders and maintain momentum of this work.

Consulted with Universities in Scotland, the UK and Internationally to identify gaps in education provision.

Surveyed and facilitated focus group sessions with all remote, and rural NHS boards, to identify additional educational competencies.

Collaborated with stakeholders, via a seminar to inform them of the identified competencies and provide opportunity to review these.


Support remote, rural and island practitioners, to provide safe and effective care.

Establish an accessible, affordable and inclusive educational pathway that meets the changing needs of the remote and rural healthcare workforce.

Increase access to rural advanced practice education, ultimately supporting the G.P. Primary Care Contract, the Transforming Roles Programme, supporting integrated multidisciplinary team working.

A national perspective is being developed across Scotland’s Universities and Remote, Rural and Island NHS Board areas to deliver evidence based, socially accountable health education that focuses on addressing inequities and addresses the evolving needs of the population.

Often working in isolation, Rural Advanced Practitioners are extended generalists. They work autonomously and collaboratively to promote health and well-being and contribute to addressing inequality in health outcomes. 2.Based on identified community needs and strengths, they work with statutory, private and voluntary providers to help build community strengths, assets, resilience and mitigate against health inequality, to prevent disease and improve health outcomes identified community needs and strengths, they work with statutory, private and voluntary providers to help build community strengths, assets, resilience and mitigate against health inequality, to prevent disease and improve health outcomes. 3. Rural Advanced Practitioners assess, diagnose and manage patients with emergencies, minor injuries/ailments, long term and complex health conditions. They have the authority to order and interpret diagnostic laboratory tests and prescribe medicines within their areas of competence. They develop effective professional networks with primary, secondary, tertiary, statutory, retrieval and voluntary services that enable safe, seamless patient care at, or as near a patient’s home as possible.

【Background】As of 2022, there are 90,000 people over 100 years old in Japan, and this number is expected to increase to 700,000 by 2050. It is expected that medical care for centenarians will become more common.
【Objective】To understand the current characteristics of house call patients over 100 years old, and to obtain suggestions on points to be examined and points to be paid attention to in medical care by knowing their clinical characteristics.
【Methods】Clinical characteristics of 12 elderly patients over 100 years old treated at Family Clinic Nagomi, Yodogawa-ku, Osaka, Japan, from 2018 to 2022 were descriptively analyzed.
【Results】 Male/female ratio = 5:7, average duration of treatment at the clinic after 100 years of age 30 months, 7 patients currently being treated, 5 deaths (as of January 1, 2023) 6 institutionalized patients, 6 home patients, 12 oral intake patients, 0 prescribed antipsychotic drugs. Major diseases included diabetes 0 patients, hypertension 6 patients, chronic heart failure 4 patients, dementia 10 patients 4 patients over 100 years of age with a history of hospitalization (3 of them were hospitalized for pneumonia)
【Discussion】 The characteristics of the elderly patients over 100 years old were that they were able to take oral intake until the end of their life and did not take antipsychotic medication. it is advisable to pay attention to the presence or absence of prescription of antipsychotic medication when examining the elderly patients over 100 years old and avoid unnecessary prescription.

1Ypu will know the clinical characteristics of patients over 100 years old.
2 You will know the main diseases of patients over 100 years old.
3 You will know how to prevent pneumonia.