Investigating women’s health issues and help-seeking intentions in primary care in Japan: a cross-sectional study

Comprehensive care for women across life stages is increasingly emphasized, but actual care remains fragmented [1‐4]. In Japan, women’s health has conventionally been handled by obstetricians and gynecologists (OB/GYNs). However, they typically do not pay much attention to comprehensive care beyond active health problems [5]. The primary health care system in Japan is characterized by universal health insurance and free access, and primary care is provided by different specialties at any levels of medical facilities [6]. Primary care providers receive reimbursement primarily from tests and prescriptions under a uniform national fee schedule, not from counseling or complex, comprehensive medical consultation. Therefore, the nature of outpatient encounters is often problem-focused and short in time, approximately 6–10 minutes on average [6]. Infrastructure of primary care remains under development, and the number of physicians certified in family medicine by the Japan Primary Care Association (JPCA), the professional body representing primary care, is very small, 794 as of April 15, 2022 [7].

Women visit primary care more often than they visit hospital outpatient clinics [8] and many are reluctant to visit OB/GYNs [9, 10]. Hence, primary care physicians (PCPs) play an important role in delivering comprehensive, well-coordinated and preventive women’s health care. However, PCPs in Japan face challenges in doing so. They have very limited training opportunities for women’s health [11] and many of them feel they lack knowledge and skills in obstetrics and gynecology [12]. In daily practice, they may make conscious decisions about whether to facilitate women’s disclosure of women’s health issues during a patient encounter [13]. They may wonder if asking and talking about women’ health issues is irrelevant or inappropriate, even as part of comprehensive care, depending on the reason for their visit, the patient-doctor relationship, and the dialogue during their visits. From women’s perspectives, they may be hesitant to voluntarily discuss women’s health issues with PCPs for a variety of reasons [14]: concerns about unnecessary visits or bothering a physician, wasting the time, unpleasant experiences related to health services providers, and fear of the consequences of medical help-seeking. They may wonder if PCPs are the right people to ask about women’s health issues under the specialized medical system in Japan.

What are women’s health needs in primary care in Japan? To what extent are women willing to consult PCPs about their women’s health issues? Investigating women’s health issues and help-seeking behaviors, particularly among women who visit primary care for health concerns other than women’s health issues, could further expand the discussion about PCPs’ roles in women’s health care in Japan. This study aims to describe the prevalence and distribution of women’s health issues and help-seeking intentions among women in primary care.

In this article, we report the results of a cross-sectional data analysis from mixed methods research that we conducted to examine help-seeking behaviors for women’s health issues and patient experience in primary care. The study was approved by the Clinical Research Ethics Committee of Hamamatsu University School of Medicine on March 29, 2019 (19–027).

The questionnaire was distributed to a total of 294 women who visited the primary care clinics. We excluded 12 responses for incomplete answers and 22 responses of women whose reasons for their visits were women’s health issues, which resulted in 260 valid responses for analysis (Fig. 1).

Table 1 shows the demographics of the participants. The numbers (%) of participants from each clinic (A, B, C, D) were 93 (36), 44 (17), 40 (15) and 83 (32), respectively. Approximately half of all respondents visited to seek their own care on the day of the survey. The majority of reasons for clinic visits were chronic diseases (e.g., hypertension, dyslipidemia, diabetes) followed by acute illnesses (e.g., upper respiratory infections, headache, acute low back pain), laboratory tests and preventive care (e.g., immunization, health check-up). The average age of the respondents was 40.5 years old, and a majority of them (97%) had at least graduated from high school. They had an average of 5.2 clinic visits per year, and most of them had updated cervical and breast cancer screening tests within the past 2 years (68 and 69%, respectively). Approximately three-quarters of them (74%) had not been to an OB/GYN in the past year.

One hundred thirty-nine (54%) reported at least one women’s health issue. The proportion of women reporting women’s health issues was similar between those self-referring (50.4%) and those accompanying their family members (49.6%). Approximately three-quarters (74%) of them had no regular visit to an OB/GYN. There were similarities observed in age, frequency of clinic visit, cancer screening status and regular visit for OB/GYN clinic between those who had at least one women’s health issue and those who reported none. The participants with women’s health issues tended to have a higher score on health literacy, while those without women’s health issues tended to report better self-rated health and give more neutral responses to self-rated economic conditions.

Figure 2 reveals the distribution of each category of women’s health issues that the participants (n = 139) reported. Concern about gynecological cancer screening tests was the most frequently reported (39%). Menstruation-related issues, such as hypermenorrhea (30%), dysmenorrhea (26%) and menstrual irregularity (25%), occupied the top five places. A specific disease of the uterus or ovaries (27%) and menopausal symptoms (21%) were third and fifth concerns from the top, respectively.

Figure 3 shows the distribution of the help-seeking intention levels for each source of care. The overall distributions of help-seeking intentions seemed to be classified into three patterns. For PCPs, acupuncturists/chiropractors, nurses/midwives, public health nurses and pharmacists, there was a descending trend in the number of respondents as the help-seeking intention level increased. An opposite trend was observed for OB/GYN. For family/close friends and media including internet, books or magazines, the frequency peaked at a relatively high score of five. A higher number of women showed a higher level of help-seeking intention for PCPs, that is, six or seven on the scale, when they did not have regular visits to their OB/GYN. This trend was similarly observed in media. On the other hand, a greater number of women indicated the highest level of help-seeking intention for OB/GYN and nurse/midwife when they had regular visits to their OB/GYN.

The participants who showed a help-seeking intention level of five or higher had 20% for PCPs, approximately 55% for OB/GYNs, family/close friends and media, and less than 10% for nurses/midwives, public health nurses, pharmacists and acupuncturists/chiropractors.

This study is the first to our knowledge to investigate women’s health issues and help-seeking intentions among women who visit a primary care clinic in Japan. It is worth noting that approximately half of the participants reported some kind of women’s health issue, and approximately 70% of them had not visited an OB/GYN in the past year. It is also unique in that the study included women who accompanied their family members from the perspective of family care, and they also had approximately 50% reporting at least one women’s health issue. Furthermore, one-fifth of women with women’s health issues indicated a high likelihood of seeking help from PCPs.

These findings highlighted that women’s health issues need to be addressed in primary care in Japan and that PCPs must be well equipped with skills to adequately handle women’s health issues when appropriate. PCPs may be required to proactively tap into women’s concerns about women’s health issues during a clinical encounter. When initiating a conversation about women’s health issues, it seems more satisfying to women if PCPs address a broad context of health-related questions [22]. Additionally, PCPs may need to recognize that routine physical examination and medical conditions other than women’s health issues were the most common reasons for visit when women’s health issues were initially brought up in the previous study [23], which may help reduce the psychological burden on PCPs who feel discussing women’s health issues in their daily practice is irrelevant.

Gynecological cancer screening and menstrual problems were the top concerns in the study. Our results on the prevalence of dysmenorrhea, menstrual irregularity and hypermenorrhea were similar to those in the previous larger cross-sectional studies in Japan. An online survey of approximately 20,000 Japanese women aged 15–49 years revealed 74% of them had menstrual problems and 50 and 19% of them had dysmenorrhea and hypermenorrhea, respectively [20]. Another survey of over 2000 Japanese female workers showed 78% of them had some degree of menstrual pain and 17 and 28% of them had menstrual irregularity and severe dysmenorrhea, respectively [21]. Despite the differences in the target population and the definitions of menstrual problems as well as slight fluctuations in the prevalence rates, a significant number of women suffer from menstrual problems. It is essential to take and interpret a history of menstruation appropriately and determine whether the situation merits a gynecological exam, treatment or referral to an OB/GYN. For gynecological cancer screening, PCPs need to clarify what women’s concerns are and appropriately respond to them. If women are concerned about their family history of breast, ovarian and uterine cancer, PCPs require skills in properly collecting a detailed family history and providing genetic counseling as needed. PCPs should acquire adequate knowledge and examination skills to integrate a variety of aspects of women’s health care into their daily practice in an effective way.

In the previous ecology and cross-sectional studies in other countries [23‐25], the number of women who self-referred to a gynecologist for women’s health issues was 1.5 to 13 times higher than that of PCPs. However, neither study specifically targeted women who visited a primary care clinic or visualized and analyzed the patterns of help-seeking intentions across different sources of care, considering whether women regularly visited an OB/GYN. Our study results provided intriguing insights into women’s help-seeking intentions for women’s health issues. A greater number of women expressed higher help-seeking intentions to PCPs when they had no regular visit to OB/GYNs. This implies that women who do not regularly see OB/GYNs, in particular, may be more likely to regard their PCPs as right people to ask about women’s health issues. More familiarity and established relationships with their PCPs or no distinctions or preferences between PCPs and OB/GYNs for women’s health issues as help-seeking sources might explain this phenomenon.

The study revealed that a relatively large proportion of women indicated high help-seeking intentions stemming from family/close friends and media. The information that women receive from these resources could influence their interpretations of women’s health issues and subsequent help-seeking behaviors. With family as a help-seeking source, PCPs need to take a family-oriented approach [26] to deepen an understanding of their help-seeking processes within a framework of the family system. For media, the study affirmed the previous finding that the internet is the main source of information used by women who are concerned about women’s health [27]. While media, especially the internet, is convenient and makes a wide range of health information accessible while simultaneously minimizing time spent and financial cost, not all information on the internet is trustworthy. PCPs need to be aware that women may present with ideas of women’s health issues filtered through information on the internet.

The meaning and extent of women’s concern about women’s health issues may vary from respondent to respondent, and their help-seeking intentions for PCPs may be influenced by unmeasured factors, such as their PCP’s scope of practice and the quality of the relationships between PCPs and their patients. Since obstetrics and gynecological care in family medicine are at a very early developmental stage in Japan and the study was conducted in primary care clinics where several PCPs actually practice gynecology and obstetrics, women may regard these family physicians as OB/GYNs, which may add a complexity in the interpretation of their help-seeking intentions. Additionally, we used the General Help Seeking Questionnaire to assess help-seeking intentions, but this questionnaire may not be able to capture all components of the conceptual framework of help-seeking behaviors: conscious planning, perception of effort to be exerted, willingness to communicate, perceptions of the problem, and perceived support, advice or assistance [28]. Help-seeking intentions may not necessarily predict actual help-seeking behaviors. Concerns about women’s health issues and help-seeking intentions could change over time and be affected by day-by-day events, and this cross-sectional study cannot grasp these dynamics. With such limitations, our study highlights the important implication that many women could present to a primary care clinic with unrevealed women’s health needs and that it is the PCP’s roles to enhance women’s health care.

The interpretation of the results requires caution. First, not having a regular visit to an OB/GYN does not necessarily indicate that they will not or are reluctant to see them for women’s health issues. Second, consecutive sampling from a limited number of primary care clinics during a short period of time in the study could lead to selection bias. The population in the study had higher rates of cervical and breast cancer screening than the national average (43.7 and 47.4%, respectively) [29]. Additionally, the proportion of the study participants who had high health literacy was greater than that of a general population in a previous study [30]. It is possible that they had a high level of health awareness and were more likely to have reported women’s health issues, leading to reporting bias [31]. Generalizability of the results could be limited due to sampling from primary care clinics, some of which a care in obstetrics and gynecology is actively provided, in the very restricted areas in Japan. Third, ethnic/racial minorities and women with intellectual challenges were not included. Transgender and nonbinary patients might not have been adequately addressed as participants. Therefore, health issues in those populations may not be well reflected in the results. Finally, the list of women’s health issues did not include intimate partner violence, perinatal mental health or substance abuse.

A significant number of women visiting a primary care clinic had concerns about women’s health issues, and a majority of them had not regularly visited an OB/GYN. Women who do not regularly see OB/GYNs may be more willing to consult their PCPs about women’s health issues. PCPs need to be competent to handle unrevealed women’s health needs in daily practice.