In Hokkaido Suttsu town with about 3,000 people, several family physicians/general practitioners play an important role at Suttsu Municipal Clinic transferred from Hokkaido Prefectural Hospital that had significant financial burden. At that time, Suttsu town made business contact with the Hokkaido Centre for Family Medicine, changed to multiple doctors. Their speciality is family medicine/general practice. Their practice is comprehensive and continuity, is not only individual care but also community care.

As a result, the deficit before transfer was 400 to 500 million yen per year, is compressed to about 100 million yen in the current Suttsu clinic, the actual burden of the town has become about 30 million yen. The rate of consultation to medical institutions in Suttsu town among national health insurance covered insurers has continued to increase by about 1％ per year from 46.5％ in 2005 to 58.8％ in 2016. The number of patients visiting outside of the time including holidays decreased from 1011 per year in 2005 to 772 in 2016, and the number of ambulances delivered from 169 per year in 2005 to 76 in 2016.

These are thought to be the result of trusting relationships between townspeople and medical institutions being built by family medicine/general practice. There is a possibility of achieving sustainable regional medical care by increasing the number of family physicians and by enhancing the regional rotation model. In order to support these efforts, it is important to establish and develop general practitioner training system, and national policy as well.

This paper describes how Okinawa prefecture has been able to train and recruit remote physicians to protect the health of every person in remote islands of Okinawa.

During World War II, many people died in the Battle of Okinawa. In order to solve the shortage of physicians, medical care for people in Okinawa has been carried out mainly by public health nurses or medical assistants（so called Ikaiho）. Public Health Nurses were stationed in every remote island instead. The Ikaiho system was established under the US occupation.

The Okinawa government started a contract student scholarship program from Okinawa to mainland Japan. In 1967, Okinawa Chubu Hospital became the first hospital to offer post-graduate medical training in Okinawa with the cooperation of the University of Hawaii to improve the quality and number of physicians. Now, 1100 physicians have completed the University of Hawaii Postgraduate Medical Training Program with 84 currently training. Approximately 70% of the trainees have remained in Okinawa Prefecture to practice medicine.

Okinawa Chubu Hospital has been offering the “Shima Isha（Island Doctor as a solo practitioner）” family medicine residency training program to successfully train since 1996. As a result, the program has enhanced the physician workforce for the islands of Okinawa. Okinawa prefecture has been active in improving the health and medical care for people in remote areas. As a consequence, the program has enhanced the physician workforce for the islands of Okinawa.

We have a responsibility to correctly pass on what has been laid down by our predecessors（public health nurses and medical assistants）to sustainable “Shima Isha（Island Doctor）” engagement at remote island clinics in Okinawa.

The author of the Japan Primary Care Association certified physician/supervisor becomes the facility manager of a mid-sized hospital in urban areas and introduces the contents that have been addressed afterwards.

As a cooperative hospital in the area, opening a comprehensive outpatient department and treating irrespective of the symptoms, pursuing the ease of liability has resulted in an increase in the number of consulting patients. In addition, “Hospitals that are strong in clinical practice for the elderly”are listed in the policy of the hospital, and the elderly committee was held to address the spread of “Humanitude”, prevention intervention for delirium, intervention on polypharmacy, dissemination of advanced care and planning. As a result, we were able to achieve a decrease in the incidence of delirium in elderly inpatients（14％ → 9％）.

In addition, joining HPH（Health Promoting Hospital & Health Service）network advocated by WHO（World Health Organization）, implementation of square step, holding of smoking prevention lecture at elementary school for the purpose of health promotion of local residents.

By becoming a staff and administrator of the general physician, we can conduct not only provision of medical treatment but also awareness of care as well as a broader range of outpatient and hospitalization, and in the area comprehensive care age including regional health promotion activities. It is possible to promote the role of small and medium hospitals required.

The integrated community care system（ICCS） in Japan only focuses on home care for the elderly with dementia, resulting in the need to construct a communityoriented coordinating system that addresses the service delivery of all care modalities in meeting the health needs of all people in the community, namely a “genuine ICCS”. This aligns with the establishment of high-quality primary health care（PHC）, which is emphasized in the Declaration of Astana（adopted in October 2018 at the 40th anniversary of the Declaration of Alma Ata）, as a cornerstone of a sustainable health system for universal health coverage and health-related Sustainable Development Goals. In this article, we introduce the process and outcome of various initiatives that the Department of Community and Family Medicine at Fukushima Medical University has conducted over the past 13 years since its foundation in March 2006. The initiatives span administrative and multidisciplinary collaborations at six teaching practices founded by the clinics and hospitals in Fukushima Prefecture including disaster response; clinical education for undergraduate and postgraduate trainees; homestay programs; train-the-trainers programs in mental health quality improvement; scholarship and doctors' career development programs in rural and remote areas; and the benchmarking of PHC against other countries. We aspire to continue training our trainers to understand, practice and teach the principles of PHC and family medicine, and to support them so that high quality PHC can be widely established in Japan under their leadership.

After obtaining Family Practice Board in United States, I started Family Practice in Nagi-cho in Okayama Prefecture since 2001, and have been working on the Family Practice residency education. In addition, I have been working to foster nurses and pharmacists who work in communities as well as physicians and have achieved certain results.

Family Practice Nurse education is a model that leads to the accreditation system of primary care nurses at Japan Primary Care Association, and Family Practice pharmacist Residency is an effort to become an educational model in the field of the training system of Japan Primary Care Association. Nursing and pharmacist Education in the primary care, Family Practice Residency education, has educational resources that can be shared from the perspective of IPE（Interprofessional education）, and links with about 400 Family Practice residency programs nationwide are desired.

By looking back at the 18-year commitment at the Nagi Family Clinic, I would like to examine the impact of family physicians on the region in terms of primary care Nurse and Pharmacist education, which plays a new role in the region.

Along with education and research, one of a university's main missions is community contribution, such as engagement in community medicine. The establishment of a community-based integrated care system is a very important issue in future community medicine. Accordingly, faculties of medicine, which may appear distant from people's daily lives, are preparing to make greater contributions to community-based integrated care. In particular, departments of family medicine/general practice（FM/GP）are the best fit for community-based integrated care.

Faculties of medicine and university hospitals need not only hospitals but also local communities for pre-graduate education and resident training. In addition, FM/GP departments need an educational center in the local community in order to train general practitioners. At the same time, community medical institutions often lack doctors and do not have sufficient personnel or time for education. Mechanisms for collaboration between universities and the local community, based on investment by the local community, are designed to link these organizations.

The General Medicine and Primary Care Department of Tsukuba University Hospital is the first to build a community medical education station, which is designed to send general practitioners to community medical institutions as teachers to perform educational functions. General practitioners dispatched to clinics or hospitals can contribute to various elements of community-based integrated care systems. Because most of their efforts will enrich education and research, this creates a positive cycle that allows the system to evolve sustainably.

Barriers to investment include the fact that such programs may not directly improve public services offered by local governments or bring medical service fees to community medical institutions. The key to success is to obtain alignment from universities, local governments, citizens, and medical institutions regarding investment in education with the vision of training doctors who will contribute to the community.

Our hospital is a prefectural hospital, and has a history of more than 70 years. It is in a depopulated area. It had been operated by organ specialists until 2007. After 2007, it has been operated by family doctor. Until then, family doctor takes a center of community-based integrated care systems. This activity continues because the family doctors are community-oriented. This activity is working with multidisciplinary and local residents because the family doctor has a skill of coordination. And this system is built tailored to the needs of the community because family doctor has a skill of accountability. Family doctors working in depopulated areas will become more concerned about the community, and listen more to the opinion of multidisciplinary. Because the size of the hospital and the number of the staff is small, it is easy to work with multi-disciplinary. Because hospitals have multiple staff, we can share work to conduct community activities. Community-based integrated care systems will continue developing to “community-based integrated care systems as a region care”, “community-based integrated care systems as a making community”, “community-based integrated care systems as a continuity”. In order to build a high quality of community-based integrated care systems, it is necessary to develop the hospital, which is operated by family doctors in each area.

In the unprecedented super-aged society, we medical personnel and city workers will not able to make comprehensive care ideal, but citizens should do it in a community-based way. At Takahama town in Fukui prefecture, citizen-led medical renovation by the Association of Community Action for Health and Unity and community-based social renovation for health in social capital and community-based participatory research（CBPR）have been conducted effectively for ten years. There are several key points, that are collaboration among citizens, city workers and medical personnel, activity support by city workers and medical personnel, citizen-led activities, and renovating activities to match changing situations of Japanese communities. General physicians are required to act effectively in community renovation by their competencies such as coordination and community-oriented approach.

The progress in aging and the shortage of physicians is a significant problem in Japan. Many kinds of healthcare professionals should cooperate to support medical services in the community. Recently, it is said that healthcare staff should use Task-Shifting in the team medical care as an effective way to keep medical care quality.Particularly, community pharmacists are expected to make appropriate proposals for consultation behavior, or provide the patient's information regarding the change in their physical condition to a physician after dispensing their prescription.

In order to achieve that, pharmacists should have the skills to gather medical information based on the concept of clinical diagnosis, but it is said that pharmacists don't have enough skills to conduct necessary procedure.

We made an education program for pharmacists called “Skill Mix Program”, and investigated the effect of the program. We train pharmacists using this education program aiming that pharmacist take a role of community health care. In addition, we made a tool to help pharmacists gather the information about medical history. This tool was made by pharmacists and physicians.

We think that the community pharmacists who can cooperate with another medical staff such as physicians or nurses, to maintain community healthcare system, is necessary because the medical demand anticipated to be expanded.

Using a repeated national wide child-rearing household survey, this paper tackles factors driving mothers to abuse their own children. We find that the mother’s physical health condition, mental illness as well as scarcity of economic and social resources have significant impacts on the probability of child maltreatment occurrence. Put differently, mothers who are in bad health condition, mothers who have depression symptoms, and mothers who are former victims of domestic violence have a relatively high probability of child maltreatment. Additionally, mothers who are living in severe material deprivation environment（etc. in poverty）, and mothers who lack accessible child care assistances are more likely to be perpetrators.

Turning to specific types of maltreatment, we find that physical abuse is more likely to happen in big families with a lot of siblings. Neglect is more often reported in single parent families and families bearing low-birthweight child.

The mental condition of mothers is associated with the quality of children's upbringing and daily life. This research aimed to explore qualitatively the possible relevance of mothers' psychological well-being to parenting difficulties of children with developmental disabilities and relationship with family members. In total, 25 mothers of children with developmental disabilities/suspected developmental disabilities were interviewed, and the interviews were conducted according to a semi-structured interview guide designed to grasp parenting difficulties in daily life. The Center for Epidemiologic Studies Depression Scale（CES-D）was used in examining the depression level in these mothers. The qualitative data were analysed using the Framework method, whereas quantitative data（CES-D）were analysed using Statistical software（Easy R）. The main findings are as follows. The average CES-D score was 15.9（± 10.2）, out of the possible score range of 0 to 60; a score over 16 indicated the presence of depressed symptomatology. Based on their CES-D score, 14 mothers（56%）were categorized into the well-being group, and 11 mothers（44%）, the depressed group. This percentage indicated a higher incidence compared with the rate of depression in Japan of 3% to 7%, as reported by Ministry of Health, Labour and Welfare in 2011. Almost all of the respondents, regardless of group, expressed thinking about their children's short- and long-term future as their utmost concern as a mother. Participants in the depressed group who were mothers of boys tended to concerned that their sons' sexual interest in girls would lead to them becoming sexual offenders. Consequently, the mothers' poor psychological condition could be attributed to relationships with their family and affect the quality of their parenting. Meanwhile, the well-being group was characterized by their ability to seek good stress relievers from daily parenting, whereas the depressed group experienced the difficulty of unrelieved, mounting stress. These results suggest that mothers' mental health could be influenced by concerns over their children's sexual behaviours and related issues, as well as by subjective stress.