primary health care thesis

• Open access
• Published: 09 November 2023

People-centred primary health care: a scoping review

• Resham B. Khatri 1 , 2 ,
• Eskinder Wolka 3 ,
• Frehiwot Nigatu 3 ,
• Anteneh Zewdie 3 ,
• Daniel Erku 4 , 5 ,
• Aklilu Endalamaw 1 , 6 &
• Yibeltal Assefa 1  

BMC Primary Care volume  24 , Article number:  236 ( 2023 ) Cite this article

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Integrated people-centred health services (IPCHS) are vital for ensuring comprehensive care towards achieving universal health coverage (UHC). The World Health Organisation (WHO) envisions IPCHS in delivery and access to health services. This scoping review aimed to synthesize available evidence on people-centred primary health care (PHC) and primary care.

We conducted a scoping review of published literature on people-centred PHC. We searched eight databases (PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science, and Google Scholar) using search terms related to people-centred and integrated PHC/primary care services. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to select studies. We analyzed data and generated themes using Gale's framework thematic analysis method. Themes were explained under five components of the WHO IPCHS framework.

A total of fifty-two studies were included in the review; most were from high-income countries (HICs), primarily focusing on patient-centred primary care. Themes under each component of the framework included: engaging and empowering people and communities (engagement of community, empowerment and empathy); strengthening governance and accountability (organizational leadership, and mutual accountability); reorienting the model of care (residential care, care for multimorbidity, participatory care); coordinating services within and across sectors (partnership with stakeholders and sectors, and coordination of care); creating an enabling environment and funding support (flexible management for change; and enabling environment).

Conclusions

Several people-centred PHC and primary care approaches are implemented in HICs but have little priority in low-income countries. Potential strategies for people-centred PHC could be engaging end users in delivering integrated care, ensuring accountability, and implementing a residential model of care in coordination with communities. Flexible management options could create an enabling environment for strengthening health systems to deliver people-centred PHC services.

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Introduction

The concept of “integrated and people-centred care” comprises two overarching concepts: integrated and people-centred care. The first concept, integrated care, is advanced from conventional illnesses-oriented and disease-focused health care. Illnesses-oriented care focuses on illness and cure, episodic consultation, and users as consumers purchase care. In contrast, disease-focused care refers to the management of diseases and priority disease control interventions, including their risk factors [ 1 ]. Additionally, integrated care means putting people and communities (not diseases), at the centre of health systems and empowering people and communities to take charge of their health by ensuring well-coordinated care around their needs, responding to fragmentations of care, and improving quality and cost-effectiveness rather than being passive recipients of services [ 1 , 2 ].

Furthermore, integrated care emphasizes holistic care to improve population health and wellbeing with continued care across the life course, around needs with shared responsibility and accountability [ 3 ]. Ensuring integrated care empowers people to tackle the determinants of ill-health through systems thinking and partnerships, encouraging them to become co-producers of care in multilevel (individual, organizational and policy) systems [ 3 ]. Thus, integrated care is best understood as a set of practices intricately shaped by contextual factors to improve health status, and reduce morbidities and mortalities [ 4 ].

Moreover, the second concept, i.e., people-centred care (PCC) is derived from patient and person-centred care. In the late 1960s, patient-centred care (different from illness-oriented care) was introduced and continued for several decades, opposing previously prevailing bio-medically oriented and paternalistic views of healthcare [ 5 ]. Patient-centred care aims to make a functional life, affirming the ethical principles of respect for persons and justice, striving to make the health system more responsive to the health services needs [ 5 , 6 ]. Advocates of market solutions to healthcare have been adopting patient-centred care by arguing for improved flexibility of consumer-oriented health care options and enhancing individual choice [ 7 ]. In contrast, person-centred care refers to caring for a meaningful life, and is a further development of patient-centred care based on personal philosophy, where the person denotes human and distinguishes from everything else [ 5 ]. Primarily, PCC is an expansion of patient-centred/person-centred care where people are involved in a care cycle, including the public, healthcare practitioners, and care organizations or systems. The PCC focuses on organizing principles for integrated care as a service innovation relating to individual service users, families and concerned communities [ 2 ]. Transforming the health care system towards people-centred health care requires action at four levels of the system: i) individuals, families and communities; ii) care providers; iii) health organizations; and iv) health systems [ 8 ]. The PCC is associated with better care continuity, considered care delivery by frontline workers within the health system, and responsive care practices and service utilization [ 9 , 10 ].

The World Health Organization’s (WHO) Framework on integrated people-centred health services (IPCHS) combines the concepts of integrated care and people-centred care [ 11 ]. The framework envisions that all people have equal access to quality health services, co-produces health care to meet their health needs across the life course and respect their preferences, and coordinated and quality care (comprehensive, safe, effective, timely, efficient, and acceptable) along the continuum by all skilled and motivated carers and work in a supportive environment [ 11 ]. The conceptualization of integrated PCC puts people’s needs first in designing and delivering health services with principles of quality, safety, longitudinality (duration and depth of contact), closeness to communities, and responsive care (equity in access, quality, responsiveness and participation, efficiency, and resilience) [ 12 ]. Specifically, the WHO framework on IPCHS outlines five interwoven strategies for management and health service delivery: engaging and empowering people and communities; strengthening governance and accountability; reorienting the model of care; coordinating services within and across sectors; and creating an enabling environment and funding support [ 13 , 14 ].

Primary health care (PHC) is a whole-of-society approach to organize and strengthen national health systems to bring health services closer to communities. The PHC approach comprises integrated health services to meet people’s health needs throughout their lives, addressing the broader determinants of health through multisectoral actions and empowering communities to improve health [ 15 ]. While primary care is a first level of care, it is usually delivered from prehospital, peripheral health facilities, and community settings [ 3 ]. People-centred PHC is the foundation of health systems that prioritize people first and have the potential to address diverse health needs by putting people and communities at the center of the system, empowering personalized health decision-making, and adapting health services to the local socio-cultural context [ 16 ]. Current body of literature focuses on people-centred integrated health services, especially medical care in hospitals, or family medicine or care by general practitioners. Nonetheless, there is a dearth of research that synthesize standalone studies on people-centred PHC and primary care using the WHO’s IPCHS framework. Thus, this study aimed to synthesize evidence on people-centred PHC interventions and strategies, their issues, and challenges. The findings of this review could inform strategies for strengthening the health system towards people-centredness in PHC systems and delivery and utilization of services.

This study is a scoping review of the literature reporting people-centred PHC services/ primary care. A scoping review method helps to synthesize and analyze existing literature on a topic and map the scope of available evidence. The process involves six steps: identifying the research question; identifying relevant studies, selecting studies; charting data; collating, summarizing, and reporting results; and consultation (optional) [ 17 , 18 ]. We employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to support comprehensive reporting of methods and findings (Supplementary Information, Table S 1 ) [ 19 , 20 ].

Identifying the research question

We identified the research question focusing on people-centred PHC/primary care services. The key research question was to review and synthesize the evidence on issues and challenges related to people-centredness in PHC/primary care services. We brainstormed on two concepts: people-centred care and PHC/primary care. These concepts guided identifying search terms under each concept and developing search strings. Our research team assumed that the proposed research question is broad to provide a breadth of issues to be explored in the review. The research question was further clarified by preliminary discussion among authors and agreed on the scope and significance of the topic.

Identifying relevant studies

We searched eight databases (PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science, and Google Scholar). The search strategy was built on two key concepts and related search terms: People-centred care (patient centred care, people centred care, person centred care, patient-centred care, people-centred care, person-centred care, patient centered care, people centered care, person centered care, patient-centered care, people-centered care, client-centered care, client centered care, person-centered care); Primary Health Care (primary health care, public health care, community care, primary care, primary care nursing, family medicine, family practice, general practice) on each database. Boolean operators (AND/OR) and truncations (“”, *) varied depending on the database. The search included all studies published in English until 30 January 2023 (no starting date was applied in the search). No country-related limitations were applied.

Selection of studies

We included all studies that dealt with PCC regardless of their designs. Based on the title and abstract, screening was undertaken initially by the first author and further assessed by the second author. This was followed by a full-text screening initially by the first author and evaluated by the second and third authors. Any disagreements were resolved by discussion with the last author. We applied some post hoc inclusion and exclusion criteria based on the research question and new topic familiarity through reading the studies. For example, we included studies considering the population (health service users, care providers and managers), concept (PCC/integrated care), and contexts (PHC and primary care systems) of the study [ 21 ]. We included studies if their findings can answer our review question rather than the quality of individual studies. We followed the standard scoping review PRISMA-ScR checklist [ 19 , 22 ] and took reference to previous scoping reviews [ 23 , 24 ]. The included studies are based on the findings and their interpretation rather than the inclusion criteria [ 25 , 26 ].

Charting the data

A data-charting form was developed to extract data from each study covering author, year, country, type of study, key concepts, and main findings (Supplementary file, Table S 2 ). Data were extracted by the first and double-checked by the second and last authors.

Collating, summarizing, and reporting results

The first author did data analysis with guidance and support from the last author. Thematic analysis of data was conducted by adopting Gale’s framework method [ 27 ]. This analysis method adopts multiple steps such as collection of raw data (main findings about the research question for this review), familiarisation with data, paraphrasing of data/label according to the nature of data, developing/applying the analytical framework, charting data into the framework matrix, and finally interpretation. After reading and familiarisation the data, we extracted important concepts/categories and grouped them (with similar ideas) into the five components (engaging and empowering people and communities; strengthening governance and accountability; reorienting the model of care; coordinating services within and across sectors; creating an enabling environment and funding support) of the WHO ICPHS framework. Within each component, themes were generated by grouping similar categories/ideas and concepts. Findings were reported in three forms; first, outcomes of database search results were presented in the flow chart. Second, a customized summary of the data charting table (covering the author, location, and key ideas related to the research question) was presented. Finally, generated themes were explained and interpreted in the narrative paragraphs under each component of the analytical framework.

A search yielded 4494 records from all databases (Fig.  1 ). We removed 2090 duplicated records. Then, studies were screened for relevance based on title and abstract, whereby 2321 were excluded, leaving 83 studies for full-text screening. A further 31 studies were excluded after the full-text screening with reasons. A further 52 studies were included in the final review.

PRISMA-ScR flow chart showing the selection of studies for the review

Overview of included studies and generated themes

Table 1 presents an overview of studies included in the review, including countries where studies were undertaken, and each study mapped with generated themes. Of 52 studies, 39 were from high-income countries (HICs): 19 studies were from the USA, eight studies were from Canada (4) and the Netherlands (4), six studies were from the UK (3) and Australia (3), four studies were from Norway (2) and Sweden (2), and one each from Greece and Finland. Two studies were from upper-middle-income countries (UMICs), including one from multi-country (Latin America), Mexico, and South Africa. Three studies were from low-and lower-middle-income countries (LMICs), including one from Nigeria and two from Uganda, and seven studies were not specified. Of five strategic components of the ICPHS framework (Table 1 ), 26 studies described engaging and empowering people and communities (light black); 32 studies included strengthening governance and accountability (blue); 45 studies explained reorienting the model of care (pink); 34 studies incorporated coordinating services within and across sectors (yellow); and 33 studies discussed creating an enabling environment and support for funding (green).

Engaging and empowering people and communities

Empowering and engaging people provides the opportunity, skills and resources needed to be articulated and empowered end users of health services and advocates for a reformed health system [ 13 ]. Two themes are described in this component: community engagement in health care (11 studies) and empathic empowerment (17 studies) related to PHC/primary care services.

Community engagement

The use of the PCC practices facilitated an ongoing relationship between end users (providers and service users) through a team relationship, timely communication, and care plan (e.g., enhanced coordinated, comprehensive care) [ 29 , 33 ]. Additionally, peers promoted norms to other service users and worked together to improve routine care practices [ 31 , 34 ]. Reinforcement of people engagement and positive perception improved people-centred primary and hospital care [ 41 , 54 , 59 ]. Contextual factors influencing PCC included perceptions of involvement, engagement, and co-creation of processes to achieve physical and social well-being for persons with multimorbidity [ 50 , 51 , 71 ]. Nonetheless, only the positive perception of the public filled the limited expectations, and service users’ voices were less incorporated, which decreased the traditional system's authority [ 41 , 53 ].

Empowerment and empathy

Empathy, communication in multicultural languages, people’s involvement in making decisions and designing and implementing solutions effectively empower individualized care for their health [ 57 , 59 , 61 ]. Empathic support, communication with their doctors, understanding of problems, providers’ skills, and management plans were required for improved satisfaction and the effect of interpersonal care [ 61 , 62 , 70 ]. Communication between service users and providers enhanced high perceived empathy in consultation, trust in relationships, and positive experiences and satisfaction [ 50 , 62 ]. The trusted relationships with providers, their involvement in care treatment decision-making, and emotional support from family and friends found effective people-centredness in care delivery [ 45 , 67 , 68 , 77 ]. Local arrangements for service integration, multi-professional teams, and co-location also supported building relationships for community empowerment [ 75 , 79 ].

Nonetheless, weak communication between individuals and practitioners was reflected in daily care practice activities and had poor priority in service delivery [ 73 , 75 ]. Factors of poor empowerment in care continuity were lack of flexible design, high administrative tasks, limited appointment time, poor autonomy, and unavailability of providers [ 56 , 64 ]. Several factors, such as intra- and interpersonal (e.g., perceived reluctance to engage in care), and organizational (e.g., limited encounter time, lack of discussion, psychological issues with health workers), also influenced understating the problems and health service needs [ 60 , 62 , 78 ].

Strengthening governance and accountability

Strengthening governance requires a participatory approach to policy formulation, decision-making and performance evaluation at multilevel health systems, from policy-making to the service delivery level [ 13 ].Two themes under this component were: organizational leadership (18 studies) and mutual accountability (15 studies).

Organizational leadership

Strategies to strengthen organisational leadership, human capital, and facilitating adaptive culture and innovation contributed to innovative PCC primary care services [ 32 ]. For instance, the people-centred medical home (PCMH) model created an enabling environment for delivering quality care, reduced care costs, and organizational needs, and incorporated people’s voices into governance and accountability for operations [ 36 , 53 , 59 , 63 ]. The role of professional councils (e.g., nursing, or general practitioners’ organizations) could be instituted to measure people-centredness for the implementation of PHC [ 58 , 76 ]. Similarly, increased local leadership, team communication, and high physician engagement with service users facilitated the successful implementation of people-centredness in PHC [ 37 , 46 ]. Multiple stakeholders offered an opportunity for reform and gaining an inclusive vision of PCC in Uganda [ 57 ] and Greece [ 52 ]. Furthermore, the use of digital technology supported the functionality of clinical information aligning with organizational support, availability of community resources, clinician interactions, and gap payment funding models to incentivize care workers [ 42 , 63 , 67 ].

However, the people-centred integrated care process failed to identify long-term goals, provide shared long-term care, and monitor and evaluate health care delivery for people with multimorbidity [ 47 ]. Furthermore, organizational and policy impediments (e.g., state decisional capacity laws and financial crisis), lack of documentation or low priority also impacted the delivery of integrated PCC [ 35 , 39 , 52 , 78 ].

Mutual accountability

Understanding the health system and integrating different dimensions of care ensured the changing needs of people with complex chronic illnesses [ 49 , 54 ]. Integrated responsiveness and relative priority for the cultural change improved client and professional interaction towards organized care [ 54 , 59 , 63 , 69 ]. The government policy in health system organizations assessed incentives for care coordination to meet complex needs [ 36 , 41 , 78 ]. Innovations and people-centeredness shaped the access to health facilities, costs, users’ perceived quality of care and expectations, and availability of free services [ 53 , 62 ]. Furthermore, approaching interpersonal and coordinated multidisciplinary teamwork, consultation on preventive and promotive measures supported people receiving treatment, medical information, and skill mix care practice towards people-centred holistic care [ 60 , 66 , 71 , 74 ].

Nonetheless, fragmentation, segmentation, limited funding, insufficient coverage, poor quality, ageing and chronic conditions, and lack of effectiveness and sustainability were multilevel challenges to achieving mutual accountability towards PCC [ 68 , 72 ]. Other influencing factors of mutual accountability were limited understanding of professional identities, roles, and responsibilities in continuity of care and service integration [ 75 ].

Reorienting the model of care

Reorienting the model of care means ensuring that efficient and effective health care services are designed, purchased and provided through innovative models of care that prioritize primary and community care services and the co-production of health [ 13 ]. Three themes generated in this component were: residential and home-based care (11 studies), care for people living with multiple chronic conditions or multimorbid conditions (21 studies), and participatory care (30 studies).

Residential and home-based care

The residential model of care, known as the patient-centred Medical Home (PCMH), is a new form of transformation in healthcare that offers an interprofessional model by connecting services and management in a primary care setting [ 28 , 36 , 61 , 79 ]. The centrepiece of transformation for primary care in a residential health care model restored confidence in quality of care and resulted in reduced care costs of hospital-related outcomes [ 36 , 63 ]. Such a model that was developed in iterative phases (e.g., planning, acting, observing, supporting and transforming care practices) met the needs of people’s priorities, improved holistic and more people-centred care in primary care, and addressed the health needs of disadvantaged communities [ 29 , 38 , 53 , 74 ]. The residency-affiliated community group family medicine provided goal-directed care for people with complex health problems (functioning, social situation, support and empowerment, and care satisfaction). It ensured self-management at home (e.g., engaging with nurses, telehealth, medication plans, and interactions) [ 29 , 35 , 74 , 78 ]. Positive effects of functional residential care improved satisfaction, informal and formal caregivers in clinical screening as high-risk groups, and delayed placement [ 63 , 79 ]. However, home-based residential care was unsuitable for managing several disease-based care pathways and specialist care to address individuals' needs for people with substantial comorbidity [ 35 ].

Care for people with comorbidities

PCC brought the management of chronic diseases to a new dimension of care (legitimizing the illness experience, acknowledging service users’ expertise, offering hope and providing advocacy) [ 30 ]. People with multimorbidity viewed PCC as a well-coordinated, respectful, supportive care long-term management of medical problems and prevention and promotion through behaviour change interventions [ 36 , 60 , 62 ]. Approaches of PCC in the management of comorbidities were effective communication, information, knowledge sharing, understanding demonstration of provider’s multidimensional skills, and agreement about treatment plans [ 39 , 57 , 69 ]. Additionally, care from non-physicians found important in comorbidities; for instance, pharmacists provided direct care services, ensured access to community resources, assisted care transitions, and provided interprofessional education [ 28 ]. Diabetes specialist nurses expressed needs that diverge and converge for people with diabetes [ 56 ]. Developing training for health care providers for self-management interventions and self-care practices positively impacted people with chronic diseases [ 42 , 48 ]. Such care practices brought the benefit of clinical care, active involvement in care, and shifting from disease-focused to people-centred PHC [ 34 , 35 , 49 , 74 ]. Furthermore, the Family Health Team and multidisciplinary providers pursued continuity and care coordination, allowing site-specific program implementation and commitment to timely delivery of health services [ 37 , 40 ]. Interdisciplinary teams and informal caregivers enabled people-centred medication therapy for older people, management services with continuous quality improvement initiatives, and inpatient family medicine service [ 28 , 63 , 78 ]. Nevertheless, understanding variations between GP practices and poor documentation of records of people-centeredness had challenges in applying evidence-based medicine [ 39 , 43 ]. Additionally, some of the populations (e.g., migrants and refugees) were neglected in the management of chronic disease, had gaps in irregular care and providers, lack of information (medical history to solve health problems), and limited time spent with the people [ 41 , 52 , 78 ].

Participatory model of care

Designing participatory and holistic or whole-person care (e.g., respect and value, choice, dignity, self-determination, purposeful living), and had the potential to address multiple dimensions of care for wellbeing (e.g., physical, mental, and social needs) by knowing and confirming tailored health plan, inter-professional teamwork, and care provision in collaboration with families [ 31 , 44 , 51 , 52 , 64 , 66 , 74 , 77 ]. Understanding the participatory approach of PCC informed quality of care (e.g., availability of medication, shorter waiting times, flexible facility opening hours, courteous health workers) for care for ageing problems [ 62 , 65 , 70 ]. The care process for people with social and health complexity (for health needs of older adults, and referral practice) was found effective in primary care to adapt peoples’ preferences [ 54 , 70 ]. There was effective communication by using electronic health records to people with complex health issues that supported the involvement of people and families in health care (e.g., practice set-up, planning, and change in consultation) [ 39 , 45 , 49 , 57 , 69 , 72 ]. Participation of people built trust through shifting the role of self-care based on medical knowledge and pragmatic experience of engagement in care process, and ensuring provider relationship and guidance [ 33 , 34 ]. Participation of service users (e.g., obtaining feedback, engaging stakeholders, adapting PCC quality improvement for better quality care) improved service integration and practices [ 42 , 75 , 77 ].

Participatory and coordinated care enhanced joint working, fostering communication and professional cultures (shared beliefs and values) by exploring and prioritizing the problems (e.g., knowing the person, identifying problems, prioritizing care, treatment, evaluating decisions and implementation) [ 72 , 73 , 75 ]. Approaches to co-design and co-creation built trust, partnering with professionals and users, communities, and individuals experience [ 51 , 66 , 74 , 77 ]. Strategies of participatory care included evidence-based decision practice, enhancing interdisciplinary team approach to continuity of care, developing training for providers, involvement of people in sharing experience (e.g., empathy in consultation, physical and social wellbeing), and providers' attitudes (open communication, caring behaviours) [ 48 , 50 , 51 , 54 , 58 ]. Furthermore, system responsiveness for quality care (e.g., affordable, coordinated, accessible) moved towards the long-term goal of universal access [ 38 , 47 , 72 ]. However, challenges such as the unavailability of family physicians, limited information and communication technology, and heterogeneity of people-centred quality improvement influenced the integrated people-centred primary care among disadvantaged populations (e.g., refugees) [ 52 , 55 ]. In some public facilities, the care process was unseen and disrespected, lacking continuity, transition, and coordinated care [ 61 , 68 ].

Coordinating services within and across sectors

Coordination requires integrating care providers within and across health care settings, developing referral systems and networks among levels of care, and creating linkages between health and other sectors [ 13 ]. Two themes were described under this component: partnership with stakeholders and sectors (24 studies) and coordination for quality care (14 studies).

Partnership with stakeholders and sectors

Partnership with other sectors supports engagement in people-centred PHC. Involvement of stakeholders and sectors (e.g., trust, understanding of purpose, clarity of expectations, and power-sharing) facilitated priorities for care evaluation and treatment outcomes [ 71 , 74 , 76 ]. Developing partnerships and team-based approaches (appointment tool guide communication) with people experiencing complex diseases to reduce stigma, social and relational integration for care coordination, and self-management [ 35 , 36 , 64 , 77 , 79 ].

Communication technology support partnership with other sectors. Communication technology and resources support non-physician healthcare providers [ 38 , 78 ]. Integrated health information technology was perceived as effective in the organization and management of chronic diseases, including the medical and care needs (discharge-related information sent from the hospital and care providers linking the care process) [ 32 , 39 , 40 , 48 ]. Electronic resources supplemented clinic visits through direct communication with people and providers [ 64 ]. Information technology supported the development of ongoing partnerships in innovation and integrating medical and social care to manage chronic illnesses, research, and practice [ 30 , 31 , 32 , 44 , 52 , 78 ].The development integration of technology (e.g., mhealth tools and high-tech and high-touch technology) supported in identifying and engaging high-risk populations [ 53 , 64 , 77 ].

More attention toward changing the organization of the electronic health records system streamlined documentation work of care visits/encounters [ 45 , 56 ]. Improved application, user-focused optimization efforts and tool functionality enabled to address the issues of access, health service and health literacy [ 46 , 59 ]. At the same time, clinicians adopted information technology with the perceived value of data sources enhanced the development of interventions for people living with multimorbidity [ 31 , 48 , 59 ]. Updated electronic health records data analytics incorporated organization-wide procedures (staff, time management, cultivating staff collaborations) and follow-up services in PHC settings [ 39 , 46 , 56 ]. However, coordination and partnership with stakeholders had challenges in healthcare organizations, including work practice discrepancies and lack of enforcement agencies [ 36 , 56 , 76 ]. Additionally, the potential of information challenges influencing PCC was the lack of data protection laws (including documentation and dissemination, time pressure, and conflicting financial incentives) that impeded the use of digital records in care [ 68 ].

Coordination and communication

Prerequisites in co-creating optimal health care practice with and for older people and their expectations influenced the implementation of biomedical and public health interventions and quality of care [ 62 , 66 ]. Coordinated care supports user-driven healthcare decision-making for quality improvement (reducing cost, relationship with providers), a perceived measure of quality care [ 64 , 67 ], common perception, and sustainable primary care models to ensure quality care for physical and emotional health [ 50 , 67 ]. Engaged physician-service users communication found that professionals care (dignity, respect, prioritize, and individualized care) for people with multiple health needs [ 60 , 78 ]. Furthermore, the coordinated care of frontline staff in communicating with other stakeholders can address social and economic issues to implement quality integrated care [ 53 , 63 ], instead of describing the holistic/whole person and PCC approach. GPs’ narrow disease-specific focus of guidelines was inappropriate for addressing people’s needs and health priorities[ 43 ]. Challenges in designing and implementing PCC interventions that hindered the delivery of integrated care were lack of clarity around responsiveness and readiness, lack of information and coordination of care, lack of integrating electronic health records in work practice (preferences, information, and education) [ 41 , 45 , 57 , 68 , 69 ].

Creating an enabling environment

To implement strategies of four categories, it is necessary to create an enabling environment that brings together all stakeholders to undertake transformational change [ 13 ]. Two themes under this component were: flexible management options (17 studies) and enabling environment (17 studies).

Flexible management for care

The flexibility of management can create an enabling environment for PCC. Practice stakeholders address the local needs expectations by redesigning health and social, professional cultures and flexible program implementation [ 37 , 75 ]. Care transitioned from hospital to home toward high-quality care that reduced unnecessary walk-in clinics and emergency department coordinating relationship building (with end users or organizations) and enhanced pharmacy services [ 28 , 36 , 40 , 42 ]. Organizational perspectives (cost-effectiveness and health care delivery processes) improved long-term goal-driven people-centred integrated care and increased people and providers relationships (including knowledge, and satisfaction) [ 32 , 33 , 34 , 47 ]. The PCMH model operationalized health services by providing a feasible reform option and solutions to people's engagement [ 28 , 36 , 44 , 46 ]. However, flexible management and implementation were influenced by challenges (lack of resources and training, excessive caseloads, poor data management responsibilities, lack of medical neighbourhood) and inconsistent implementation of practices [ 36 , 37 , 42 , 46 , 75 ]. Also, difficult communication and being invisible in the context of event-based quality of care frameworks were identified as gaps in primary care clinics [ 41 , 47 ].

Enabling the health system environment

Health workforce attributes (including the responsibility of professionals) enabled sensitizing systems (continuous supervision, professional training, empowerment for leadership) focused quality of care improvement initiatives to bring improved clinical practice [ 69 , 71 , 72 ]. Collaborative works (between a personal network of family and practitioners), upgrading of providers for quality improvement resources, alignment measurement efforts, engaging champions, and need assessment (needs/priorities for people-centred measurement) facilitated identification and management of symptoms [ 72 , 73 , 76 , 77 ]. Similarly, co-location of community health systems, organizations, and service delivery outlets found committed care boundaries that provided sufficient care responsive to their wishes and needs [ 54 , 57 , 75 ]. Mobile health tools are supported ensuring flexible management through sensitization and optimizing the environment across multiple dimensions (individual, provider, and organizational levels) [ 54 , 65 ]. Additionally, understanding common ground, exploring health and illness, valued customers, people-centredness, social and physical wellbeing and satisfaction, whole- PCC reported measures to improve health status and reduce morbidities and mortalities [ 51 , 53 , 58 , 62 ]. Nonetheless, difficulties achieving mutual understanding between end users were influenced by several challenges such as lack of training and new skills of providers, lack of trust (genuine care, respect, dignity, autonomy), poor disclosure of problems (time-compressed visit) and lack of resources [ 60 , 68 , 79 ].

This review synthesizes evidence on people-centred PHC and primary care. Major themes identified from this review were community engagement, empowerment and empathy, leadership and mutual accountability within the organization, home and community-based and participatory care, holistic care for people with multimorbidity, partnership with information technology, coordination and communication, and flexible management for delivery of people-centred PHC services. Most studies in the HICs explained people-centred medical care models with little focus research in LMICs.

There are several ways that health systems could generate and deliver people-centred and integrated care for individuals, families, and communities. Firstly, promoting respectful conversations and activities between care providers and service users is fundamental for improving community empowerment and ensuring providers’ empathy. People engagement and empowerment enhanced people-centred PHC in many contexts. Empowering traditionally disengaged communities and individuals requires awareness of social determinants of health [ 80 ]. Conversation and engagement of people can support personalized, coordinated care towards narrowing inequalities [ 81 ]. The provider’s empathy also enabled supportive, involved care, community, social enterprise, and volunteerism [ 81 ]. Inter-professional teamwork and collaboration with and for older people and relatives are fundamental to empathy and empowerment [ 66 ]. Of the five strategies of the WHO framework on IPCHS, community engagement and empowerment have little attention in the literature. The current global health initiatives, including the Asthana Declaration, have envisioned empowerment, health literacy, and understanding the public’s role in PHC [ 82 ]; community engagement could potentially promote people-centred PHC service delivery. Thus, the focus of research, policy and practices of community engagement and empathy need to be prioritized in PHC and primary care in low-income settings.

Secondly, for PCC and coordinated care, there was an emphasis on organizational integrity and mutual accountability. Strengthening leadership and accountability in home-based care increased people-centred care in PHC services [ 83 ]. Co-creation and healthcare organizations and their leadership efficiently could meet the health needs of people according to standards of care to align tactics and improve organizational reliability while paying attention to quality care [ 84 ]. Organizational leadership and mutual accountability strategies could be beneficial in recruiting people with integrity and sensitivity, the ability to notice and respond through policies of diverse staff and aligning incentives and recognitions [ 11 , 84 ].

Thirdly, some models of care, such as care for people with multiple chronic conditions or comorbidities, residential home-based care, and participatory care, were effective approaches for PCC in PHC and primary care contexts. Such care models can effectively reduce the burden of hospitalization and care costs by using PHC and primary care in prehospital settings [ 83 , 85 ]. The residential home-based model of care facilitates holistic care through collaboration between family members and providers considering the family contexts and comprehensive education and care [ 86 ]. Such a model is useful for people with multiple chronic conditions that could support the activities of daily living and produce high healthcare expenses. Functional limitations can often complicate access to health care, interfere with self‐management, and necessitate reliance on caregivers [ 87 ]. Crucial for implementing people-centred care is knowing and confirming people as a whole and co-creating a tailored personal health plan [ 66 ]. These residential care models could enhance the identification of health priorities (i.e., specific health outcomes and healthcare preferences), and clinicians align their decision-making to achieve these health priorities [ 88 ].

Fourthly, partnership with the digital and information technology sector, and tools can potentially ensure coordinated care by monitoring health records, coordinating processes, tracking health services, and involving people representatives and individuals in developing digital services and work practices. The information technology-related stakeholders are vital for mutual information sharing and distributing initiatives, tasks, and responsibilities from providers to service users [ 89 ]. The human-centred service design approach can leverage the potential of technology and advance healthcare systems, and innovative solutions for healthcare change and wellbeing; addressing the complexity of healthcare systems toward integrated care [ 90 ].

Finally, enabling and flexibly managing the health system environment is fundamental for people-centredness in the provision of delivery of PHC services. System strengthening and management requires system inputs and processes towards desired outcomes. The structural factors of organizations and systems (e.g., creating a PCC culture across the continuum of care, co‐designing educational programs, health promotion and prevention programs with people) provide the foundation for PCC, providing a supportive and accommodating environment developing structures to support health information technology and measure and monitor people-centred care performance influence the processes and outcomes [ 91 ]. The processes component describes the importance of cultivating communication and respectful and compassionate care, engaging service users in managing care and integrating care. At the same time, outcome domains identified include access to care and client-reported outcomes [ 91 ]. At the system level, the enabling environment indicates the adaptation of responses, involvement in support, engagement with professionals, use of information and communication technologies, and organization of care [ 92 ].

This study has some limitations. We included studies written only in English. This study is a scoping review of qualitative evidence in the topic. We synthesized evidence rather than grading the quality of available evidence. Synthesized evidence from this study could provide research, policy, and program insights for improved people-centred PHC services. Evidence generated from this study is primarily based on studies from HICs and upper-middle-income countries (UMICs), which can have limited contextual implications in low-income countries as the health systems contexts of LMICs are different. Therefore, future research can be conducted on specific components of people-centred care in low-income country settings.

Implementing several approaches of people-centred PHC and primary care, especially in HICs, has little priority in LMICs. Potential strategies for PCC could include engaging end users in the care process, community engagement and empowerment, mutual accountability, and institutional leadership. Some successful models of care, such as home-based residential care, are effective in care for people living with multimorbidity, and valuable in prehospital care that can reduce the care costs and burden to the health system. Flexible management options could create an enabling environment for health system strengthening in providing and delivering health services.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

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RBK: Data collection, analysis, and preparation of the first draft of the manuscript. RBK, AE, DE, and YA: conceived the study and interpreted the findings. YA: Supervision of the study. RBK, DE, AE, EW, FN, AZ, and YA: provided critical comments in the revision of the manuscript. All authors agreed and approved the final version of the manuscript.

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Additional file 1: table s1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. Table S2. A summary of studies included in the review.

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Khatri, R.B., Wolka, E., Nigatu, F. et al. People-centred primary health care: a scoping review. BMC Prim. Care 24 , 236 (2023). https://doi.org/10.1186/s12875-023-02194-3

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Bumgarner, D., K. Owens, J. Correll, W. T. Dalton, and Jodi Polaha. "Primary Behavioral Health Care in Pediatric Primary Care." Digital Commons @ East Tennessee State University, 2012. https://dc.etsu.edu/etsu-works/6597.

Polaha, Jodi. "Primary Care Behavioral Health." Digital Commons @ East Tennessee State University, 2014. https://dc.etsu.edu/etsu-works/6676.

Skånér, Ylva. "Diagnosing heart failure in primary health care /." Stockholm, 2004. http://diss.kib.ki.se/2004/91-7349-784-3/.

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Problem: Medical and nursing literature poorly identify primary care providers' (PCP) relationship to care coordination (CC). Primary care providers' education, experience, and perspective, contribute to: (a) assessments of patient's care coordination needs, and (b) variability in behavior to address needs. Dissimilar approaches to CC by PCPs affect work relationships and office flow.

Purpose: To pre-pilot a new tool describing PCPs' knowledge, perception, and behavior regarding CC. Methods: Primary care physicians, nurse practitioners, and physician assistants were surveyed.

Analysis: Frequencies and percentages provided sample characteristics. Descriptive statistics analyzed provider responses within and between groups. Narratives were analyzed for themes. Tool refinement is suggested however, the tool does describe PCPs and CC activities.

Significance: A tool was developed to evaluate areas of CC activity performed by PCPs. Information from surveys of PCPs can illuminate behaviors that lead to improved work flow, efficiency, and patient outcomes. Doctors of Nursing Practice who are PCPs contribute to primary care CC through leadership, experience, and descriptive evidence.

Polaha, Jodi. "Integrating Behavioral Health Into Primary Care." Digital Commons @ East Tennessee State University, 2019. https://dc.etsu.edu/etsu-works/6648.

Onwuliri, Michael O. "Primary health care management in Nigeria." Thesis, Aston University, 1987. http://publications.aston.ac.uk/12207/.

Baker, Timothy Alan. "Oregon Primary Care Physicians' Support for Health Care Reform." PDXScholar, 1994. https://pdxscholar.library.pdx.edu/open_access_etds/4755.

Mukiapini, Shapi. "Baseline measures of Primary Health Care Team functioning and overall Primary Health Care performance at Du Noon Community Health Centre." Master's thesis, University of Cape Town, 2017. http://hdl.handle.net/11427/24504.

Dunkley-Hickin, Catherine. "Effects of primary care reform in Quebec on access to primary health care services." Thesis, McGill University, 2014. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=123121.

Marshall, Emily Gard. "Universal health care? : access to primary care and missed health care of young adult Canadians." Thesis, University of British Columbia, 2007. http://hdl.handle.net/2429/30948.

Temmers, Lynette. "Factors influencing the collaboration between community health workers and the public primary health care facilities in delivering primary health care services." University of Western Cape, 2019. http://hdl.handle.net/11394/7655.

Riley, Marie Danielle Melinda Mylo. "Building collaborative partnerships in primary health care." Thesis, University of British Columbia, 2013. http://hdl.handle.net/2429/44214.

Iveson, Claire. "From primary care to mental health services:." Thesis, University of Liverpool, 2002. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.490634.

Purves, Andrew Geoffrey. "The design of primary health care buildings." Thesis, University of Newcastle Upon Tyne, 2009. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.501068.

Poulton, Brenda Christine. "Effective multidisciplinary teamwork in primary health care." Thesis, University of Sheffield, 1995. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.339905.

Filipe, Luís Alexandre Coelho. "Estimating demand for primary health care services." Master's thesis, NSBE - UNL, 2012. http://hdl.handle.net/10362/9543.

Dyer, Halie, Byron Brooks, Karen Schetzina, and Jodi Polaha. "Behavioral Health Referrals in Pediatric Primary Care." Digital Commons @ East Tennessee State University, 2015. https://dc.etsu.edu/etsu-works/6624.

Beynon, Teresa Anne. "Developing education in palliative care for primary health care professionals." Thesis, King's College London (University of London), 2004. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.408772.

Baker, Robin Lynn. "Primary Care and Mental Health Integration in Coordinated Care Organizations." PDXScholar, 2017. https://pdxscholar.library.pdx.edu/open_access_etds/3616.

Jones, Roger Hugh. "Self care and primary care of dyspepsia." Thesis, University of Southampton, 1990. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.241615.

Wright, Trudy, and n/a. "Primary health care : the health care system and nurse education in Australia, 1985-1990." University of Canberra. Education, 1994. http://erl.canberra.edu.au./public/adt-AUC20061110.171759.

Al-Tuwaijiri, A. M. "Primary eye care in Saudi Arabia : an integral part of the primary health care system." Thesis, Swansea University, 1993. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.635734.

Höfter, Ricardo Andres Henriquez. "Preferred providers, health insurance and primary health care in Chile." Thesis, Queen Mary, University of London, 2006. http://qmro.qmul.ac.uk/xmlui/handle/123456789/1772.

Karki, Jiban Kumar. "Health system actors' participation in primary health care in Nepal." Thesis, University of Sheffield, 2016. http://etheses.whiterose.ac.uk/15799/.

Eisenbrandt, Lydia L., and Jill D. Stinson. "The Need for Mental Health Professionals Within Primary Health Care." Digital Commons @ East Tennessee State University, 2016. https://dc.etsu.edu/etsu-works/7900.

Jama, Mahmud Amina. "Designing ICT-Supported Health Promoting Communication in Primary Health Care." Doctoral thesis, Blekinge Tekniska Högskola, Sektionen för hälsa, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:bth-00571.

Haas, Marion. "The benefits of health care beyond health an exploration of non-health outcomes of health care /." Connect to full text, 2002. http://hdl.handle.net/2123/854.

Meebunmak, Yaowaluck. "Community mental health care in Thailand: Care management in two primary care units." Thesis, Meebunmak, Yaowaluck (2009) Community mental health care in Thailand: Care management in two primary care units. PhD thesis, Murdoch University, 2009. https://researchrepository.murdoch.edu.au/id/eprint/6502/.

Ninh, Teresa T. "Driving factors that affect primary care utilization." Thesis, California State University, Long Beach, 2013. http://pqdtopen.proquest.com/#viewpdf?dispub=1523084.

This study was conducted to identify the driving factors that affect primary care utilization. It hypothesizes that the cost of treatment is the driving factor that affects a patient's decision to seek medical care from their primary care physician. Furthermore, it also hypothesizes that the uncomfortable conversation with the physician, the concern of someone else finding out about the patient's personal health problems, and the trouble of making an appointment are three independent factors that do not affect primary care utilization. In order to test these hypotheses, secondary data from the CHIS 2009 was collected and analyzed. Unfortunately, the data sets concerning these three independents variables were not released as they were classified to contain confidential data. As a result, healthcare coverage and emergency care utilization were served as proxy variables and were used instead to determine the factors associated with primary care utilization. Statistical analysis of these proxy variables indicates that primary care utilization is associated with health insurance coverage and emergency care utilization.

Welschhoff, Anja. "Community Participation and Primary Health Care in India." Diss., lmu, 2007. http://nbn-resolving.de/urn:nbn:de:bvb:19-69547.

Petersson, Håkan. "On information quality in primary health care registries /." Linköping : Univ, 2003. http://www.bibl.liu.se/liupubl/disp/disp2003/tek805s.pdf.

Salminen, Helena. "Osteoporosis in elderly women in primary health care /." Stockholm, 2007. http://diss.kib.ki.se/2007/978-91-7357-371-9/.

Arvidsson, Eva. "Priority Setting and Rationing in Primary Health Care." Doctoral thesis, Linköpings universitet, Utvärdering och hälsoekonomi, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-88086.

Ferreyra, Galliani Mariella. "Cultural Competency in the Primary Health Care Relationship." Thèse, Université d'Ottawa / University of Ottawa, 2012. http://hdl.handle.net/10393/23467.

Stewart, Sharon Louise. "Primary care groups : implementing the public health agenda." Thesis, University of Liverpool, 2005. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.425660.

Black, Sheila. "Teamwork in primary health care : a case study." Thesis, University of Essex, 2000. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.323029.

Webb, Katie Louise. "Management of common mental health in primary care." Thesis, Cardiff University, 2014. http://orca.cf.ac.uk/66867/.

Davis, Meagan Chase. "Adolescent Depression Screening in Primary Care Practice." Thesis, The University of Arizona, 2019. http://pqdtopen.proquest.com/#viewpdf?dispub=13864970.

Purpose: The purpose of this DNP quality improvement project was to increase primary care provider knowledge about indications for adolescent depression screening.

Background: Approximately 13.3% of adolescents experienced depression in the past year. In Oklahoma alone, rates are increasing, with depression totaling 60% of all mental health illness among adolescents. Primary care providers see approximately 75% of adolescents; however, mental health conditions are missed 84% of the time. Current clinical guidelines recommend screening for adolescent depression during wellness visits or when risk factors are present.

Methods: The providers of interest were nurse practitioners, physicians, and physician assistants providing primary care to children between the ages of 12 and 17 in a private pediatric practice group consisting of three clinics. The Model for Improvement guided the process of developing, implementing, and evaluating an educational intervention through use of a pre-test/post-test quantitative design. An email invited participants to complete an anonymous pre-test survey to evaluate knowledge and beliefs surrounding adolescent depression, then view an educational presentation on adolescent depression and screening guidelines, then complete a post-survey to evaluate any changes in knowledge and intention to screen. Results were shared with clinic representatives to help refine the education for future testing cycles and other clinic sites.

Results: Data collection took place over one week. Five providers completed both the pre-test and post-test surveys. Provider knowledge scores significantly increased 29% after participating in the education and self-reported knowledge on screening increased.

Conclusions: DNP quality improvement projects like this help develop strategies to increase best practices, leading to improved patient outcomes. Nurse-led improvement programs like this contribute to healthcare literature and the advancement of the nursing profession by developing patient-centered interventions applicable to a wide variety of providers. Results may be used to develop strategies to increase and align provider practices with best standards to help promote early identification and treatment of adolescents with depression.

Cornoc, N. S. "Quality improvement cycle for cardiac failure in primary health care : Elsies River community health centre, Cape Town." Thesis, Stellenbosch : University of Stellenbosch, 2015. http://hdl.handle.net/10019.1/97226.

Hanna, Elizabeth Gayle (Liz), and lizhanna@netc net au. "Environmental health and primary health care: towards a new workforce model." La Trobe University. School of Public Health, 2005. http://www.lib.latrobe.edu.au./thesis/public/adt-LTU20061110.152550.

Sundquist, Kristina. "Individual health, neighborhood characteristics, and allocation of primary health care resources /." Stockholm, 2003. http://diss.kib.ki.se/2003/91-7349-595-6/.

Hanna, Elizabeth Gayle. "Environmental health and primary health care : towards a new workforce model /." Access full text, 2005. http://www.lib.latrobe.edu.au/thesis/public/adt-LTU20061110.152550/index.html.

Steward, Jocelyn Louise. "Development and testing of the Primary Care Homeless Organizational Assessment Tool (PC-HOAT) to evaluate primary care services for the homeless." Thesis, The University of Alabama at Birmingham, 2014. http://pqdtopen.proquest.com/#viewpdf?dispub=3634634.

The purpose of this dissertation is to develop and test an organizational assessment tool that can used to evaluate primary care services for the homeless. The research evaluates the importance, feasibility, reliability, and validity of organizational processes and structures of primary care services for the homeless. The final product is the validated Primary Care Homeless Organizational Assessment Tool (PC-HOAT). This tool provides stakeholders with information regarding the organizational structures and processes associated with greater quality of primary care for the homeless. This tool will help managers better understand their organization's strengths and weaknesses, guide discussions regarding operations, and provide information to inform future strategies.

The researcher conducted a mixed-method study of key informants and organizations receiving federal health care for the homeless funding. The study used eight key informants to refine the initial PC-HOAT. The researcher distributed the final instrument through a web-based survey to determine reliability and validity of the PC-HOAT. Data analysis included descriptive statistics, factor analysis, and regression analysis.

The study yielded a 7-factor scale, 34-item tool focused on evaluation and delivery of primary care services, organizational structures relevant to effective delivery of care, and patient and family centeredness. In particular, the scale describing access and quality of care provided a positive statistical association with the proportion of patients with controlled hypertension. The study yielded results that provide a better understanding of the vital organizational characteristics that contribute most appropriately to the design of health care for the homeless organization.

Keywords: homeless, primary care, organizational assessment, reliability, validity, factor analysis

Snyman, J. S. "Effectiveness of the basic antenatal care package in primary health care clinics." Thesis, Nelson Mandela Metropolitan University, 2007. http://hdl.handle.net/10948/728.

Boardman, Helen Fiona. "Headache in primary care : epidemiology, management, and use of health care services." Thesis, Keele University, 2003. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.275244.

Polaha, Jodi, and J. Hodgeson. "INTRA-Disciplinary Care: Can Mental Health Professionals Work Together in Primary Care?" Digital Commons @ East Tennessee State University, 2011. https://dc.etsu.edu/etsu-works/6767.

Wood, David L. "Engaging Primary Care Providers in Health Care Transition For Persons with Hydrocephalus." Digital Commons @ East Tennessee State University, 2017. https://dc.etsu.edu/etsu-works/5171.

Slater, Julie Anne. "Occupational stress in primary health care : an investigation of the sources of stress in primary health care, the effects of these stressors on primary health care team members and the moderating effects of individual differences." Thesis, Cardiff University, 1996. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.362503.

Schokking, Ian David. "Effectiveness of outreach primary health care in Karachi, Pakistan." Thesis, McGill University, 1994. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=23297.

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Double-blind, Placebo-controlled, Randomized Study of the Tolerability, Safety and Immunogenicity of an Inactivated Whole Virion Concentrated Purified Vaccine (CoviVac) Against Covid-19 of Children at the Age of 12-17 Years Inclusive"

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Recruitment of volunteers will be competitive. A maximum of 450 children aged 12 to 17 years inclusive will be screened in the study, of which it is planned to include and randomize 300 children who meet the criteria for inclusion in the study and do not have non-inclusion criteria, data on which will be used for subsequent safety and immunogenicity analysis.

Group 1 - 150 volunteers who will be vaccinated with the Nobivac vaccine twice with an interval of 21 days intramuscularly.

Group 2 - 150 volunteers who will receive a placebo twice with an interval of 21 days intramuscularly.

In case of withdrawal of volunteers from the study, their replacement is not provided.

Inclusion Criteria:

• Volunteers must meet the following inclusion criteria:

Type of participants • Healthy volunteers.

Age at the time of signing the Informed Consent

• from 12 to 17 years inclusive (12 years 0 months 0 days - 17 years 11 months 30 days).

Paul • Male or female.

Reproductive characteristics

• For girls with a history of mensis - a negative pregnancy test and consent to adhere to adequate methods of contraception (use of contraceptives within a month after the second vaccination). Girls should use methods of contraception with a reliability of more than 90% (cervical caps with spermicide, diaphragms with spermicide, condoms, intrauterine spirals).
• For young men capable of conception - consent to adhere to adequate methods of contraception (use of contraceptives within a month after the second vaccination). Young men and their sexual partners should use methods of contraception with a reliability of more than 90% (cervical caps with spermicide, diaphragms with spermicide, condoms, intrauterine spirals).

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SARS-CoV-2 infection

• A case of established COVID-19 disease confirmed by PCR and/or ELISA in the last 6 months.
• History of contacts with confirmed or suspected cases of SARS-CoV-2 infection within 14 days prior to vaccination.
• Positive IgM or IgG to SARS-CoV-2 detected on Screening.
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• Serious post-vaccination reaction (temperature above 40 C, hyperemia or edema more than 8 cm in diameter) or complication (collapse or shock-like condition that developed within 48 hours after vaccination; convulsions, accompanied or not accompanied by a feverish state) to any previous vaccination.
• Burdened allergic history (anaphylactic shock, Quincke's edema, polymorphic exudative eczema, serum sickness in the anamnesis, hypersensitivity or allergic reactions to the introduction of any vaccines in the anamnesis, known allergic reactions to vaccine components, etc.).
• Guillain-Barre syndrome (acute polyradiculitis) in the anamnesis.
• The axillary temperature at the time of vaccination is more than 37.0 ° C.
• Positive blood test for HIV, syphilis, hepatitis B/C.
• Acute infectious diseases (recovery earl

Exclusion Criteria:

- • Withdrawal of Informed consent by a volunteer and/or a parent of a volunteer;

• The volunteer was included in violation of the inclusion/non-inclusion criteria of the Protocol;
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Victor Mukhin

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Title : Active carbons as nanoporous materials for solving of environmental problems

However, up to now, the main carriers of catalytic additives have been mineral sorbents: silica gels, alumogels. This is obviously due to the fact that they consist of pure homogeneous components SiO2 and Al2O3, respectively. It is generally known that impurities, especially the ash elements, are catalytic poisons that reduce the effectiveness of the catalyst. Therefore, carbon sorbents with 5-15% by weight of ash elements in their composition are not used in the above mentioned technologies. However, in such an important field as a gas-mask technique, carbon sorbents (active carbons) are carriers of catalytic additives, providing effective protection of a person against any types of potent poisonous substances (PPS). In ESPE “JSC "Neorganika" there has been developed the technology of unique ashless spherical carbon carrier-catalysts by the method of liquid forming of furfural copolymers with subsequent gas-vapor activation, brand PAC. Active carbons PAC have 100% qualitative characteristics of the three main properties of carbon sorbents: strength - 100%, the proportion of sorbing pores in the pore space – 100%, purity - 100% (ash content is close to zero). A particularly outstanding feature of active PAC carbons is their uniquely high mechanical compressive strength of 740 ± 40 MPa, which is 3-7 times larger than that of  such materials as granite, quartzite, electric coal, and is comparable to the value for cast iron - 400-1000 MPa. This allows the PAC to operate under severe conditions in moving and fluidized beds.  Obviously, it is time to actively develop catalysts based on PAC sorbents for oil refining, petrochemicals, gas processing and various technologies of organic synthesis.

Victor M. Mukhin was born in 1946 in the town of Orsk, Russia. In 1970 he graduated the Technological Institute in Leningrad. Victor M. Mukhin was directed to work to the scientific-industrial organization "Neorganika" (Elektrostal, Moscow region) where he is working during 47 years, at present as the head of the laboratory of carbon sorbents.     Victor M. Mukhin defended a Ph. D. thesis and a doctoral thesis at the Mendeleev University of Chemical Technology of Russia (in 1979 and 1997 accordingly). Professor of Mendeleev University of Chemical Technology of Russia. Scientific interests: production, investigation and application of active carbons, technological and ecological carbon-adsorptive processes, environmental protection, production of ecologically clean food.   

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• v.16(2); 2021 Jul 22

The role of social media in primary care

Aneesa abdul rashid.

MBBCh BAO (NUI), Dr FamMed (UKM), Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia Email: ym.ude.mpu@aseena

Islamic Medical Association of Malaysia (IMAM) Response and Relief Team (IMARET), Cheras, Wilayah Persekutuan, Kuala Lumpur, Malaysia

Malaysian Research Institute on Ageing, Universiti Putra Malaysia Serdang, Selangor, Malaysia

Ahmed Kamarulzaman

MD (Volgograd), Persatuan Pembanteras Mitos, Perubatan Malaysia (Medical Mythbusters Malaysia), Selangor, Malaysia

Klinik Awfa, KotaSAS, B2 & B4 Kuantan, Pahang Darul Makmur, Malaysia

Sakinah Sulong

Persatuan Pembanteras Mitos, Perubatan Malaysia (Medical Mythbusters Malaysia), Selangor, Malaysia

Klinik Kesihatan Masai, Johor Bahru, Johor, Malaysia

Suhazeli Abdullah

MD(USM, MMed (FamMed)(UKM), Persatuan Pembanteras Mitos, Perubatan Malaysia (Medical Mythbusters Malaysia], Selangor, Malaysia

Klinik Kesihatan Tengkawang, Kuala Berang, Terengganu, Malaysia

Online activities have become the norm. From searching for new information to conducting business meetings, social media’s role in daily life continues to grow in prominence. It is estimated that the majority of the population uses social media, and users include doctors and other healthcare professionals. It is critical for primary care doctors to note how social media can substantially influence one’s healthcare behaviour and decision making. Because primary care doctors are usually the first line of contact for patients, they are the most easily accessible and most instrumental in using social media to steer the public toward proper information on healthcare.

Introduction

It is estimated that there were nearly 4.4 billion internet users worldwide in 2019, a statistic reflective of roughly a 10% increase over that in 2018. Among internet users, 3.26 billion use social media (SM). 1 In Malaysia, 87.4% of the population are internet users and the around 40% of users spend an estimated one to four hours online daily, which is a significant amount of time. It is reported that 85.6% of users spend their time online for networking, and the most popular sites include Facebook, Instagram and YouTube. 2 These simple data alone illustrate the incontrovertible significance of SM in daily life.

Roles and Benefits of SM

In the United States, it has been reported that up to 80% of internet users have searched online for health information, which may influence their medical decision making and health-related behaviors. 3 A study conducted on an online support group for patients with prostate cancer found that almost one-third (29%) revised their initial treatment decisions after joining the support group. The researchers also learned that these patients demanded a more active role in the patient-doctor relationship and they also had more participation in conventional support groups. The above is an example that demonstrates the significance of online health communications with patients’ decision making. 4

There are many ways that doctors use SM and that transcend the professional-recreational bridge. Recreational use of SM involves interaction with individuals and elements outside of professional contexts, such as communication with relatives and friends, consumption entertainment-related content or participation in online pastimes. The use of SM is crucial in this era of digital living, but may engender negative consequences; several factors require consideration during SM use, such as potential disrespect for confidentiality, the possibility of misuse of SM platforms by patients and the risk of uploading unprofessional content. 5 Specifically for healthcare researchers and clinicians, use of SM is predominantly for both recreational and professional purposes. In a study that investigated this matter, more than one-quarter of the participants, who included healthcare practitioners and clinicians, used SM to search for research evidence, but only 15% of the participants disseminated their research findings via SM. Among the challenges faced was lack of training in SM use for professionals and concerns regarding the trustworthiness of information obtained via SM. 6 However, the younger generation appears more comfortable with the use of SM, which remains a popular mainstay among medical students and medical trainees, 7 more than 90% of whom use SM. 8

Challenges of SM

A major concern about SM use is the dissemination of incorrect health information. There are many instances in which non-health professionals who are nevertheless influential to the public relay false information. This is a worrying trend that sometimes causes detrimental consequences on a grand scale. For example, one seller may claim that the miracle pill it offers can cure numerous illnesses, only for consumption of the pull to result in end-stage renal failure and Cushing’s Disease among customers. A recent paper published on analysis of popular English-language videos about COVID-19 on YouTube reported that over one-quarter of the videos were non-factual and contained misleading information about the disease itself as well as conspiracy theories. These videos nonetheless garnered over 62 million views collectively. 9 Meanwhile, in Malaysia, SM has been reported to be a source of support and encouragement for dangerous health beliefs such as unassisted home birth and refusal of routine vaccination for children. 10 , 11

The danger of false information via SM stems from SM platforms’ ability to disseminate information within a small amount of time but within a large radius. The impact may be limited to small numbers of contacts within a family or a social circle, or the information may circulate widely during critical situations such as natural disasters and political unrest. Currently, it is still controversial whether this type of information brings more benefit than harm. Rumours triggered via SM may cause catastrophic results; 12 during the COVID-19 pandemic, a study in Iraq demonstrated a significant positive correlation between information shared via SM and public panic. The researchers reported that the 18–35-year age group was most affected psychologically. 13 However, the influence of SM on manmade and natural disasters varies significantly. In response to the former, SM functions as a fount of emotional communication that relies heavily on opinionated pundits prone to the generation of rumours. In contrast, in the build-up to and aftermath of natural disasters, SM works as a means of information dissemination for risk communication. 14

SM circles most often involve close family members, friends and acquaintances with common interests. Studies have shown family dynamics tend to have an impact on the health of a patient, 15 and similarly, SM significantly influences psychological wellbeing. 16 These are important elements likely to affect the management of patients.

Suggestions to Overcome the Challenges

The role of primary care doctors is essential in today’s age of the digital era because of their status as the first line of contact for patients, and they must communicate proper and verified health information, knowledge and support to patients. This responsibility does not come without its challenges; the rapid spread of information makes it difficult for doctors to remain informed about newer verified information, and as a result, they may not be as influential in patients’ lives as they should be.

With these factors in mind, here are four components in what primary care doctors can do to be involved with social media particularly in the digital era (see Table 1 for summary):

1. Right Mindset

Acknowledge the importance of SM

Healthcare professionals may feel that the use of SM should be restricted to recreational or social purposes only and outside of working hours, or they may exhibit diffidence about or ignorance of SM use; 6 , 17 with this mindset, many may fail to acknowledge the importance of SM in the management of patients. In a nationwide study in Australia, primary care doctors were reported to use SM more than hospital-based specialists did, thereby highlighting the potential of these platforms’ use. 17 It is essential that primary care doctors be aware of this matter because disregarding SM and its content as of little importance may cause resentment among patients and later prompt them to find inaccurate information elsewhere, such as on ‘alternative’ treatments with little or no scientific evidence. 10 , 11 As gatekeepers, it is essential for healthcare professionals to acknowledge the ideas, concerns and expectations of their patients, even if SM has influenced all three. For doctors without a SM presence, acknowledgment of an issue is an essential primary step, with subsequent advising of the patient as needed. Often, patients may echo the queries of their family members or peers, who may influence one’s health decisions, 15 which underscores the necessity for doctors to attend to queries on health-related issues on SM.

Stay updated on current trends in health topics

For those with a SM presence, keeping abreast of the latest health-related issues is paramount and will help primary care doctors to answer queries that they may field during consultation. For example, researchers have looked into Malaysian parents’ opposition to childhood vaccination and suggested that online influence may be one of the key contributing factors to this negative behavior. 11 The researchers also suggested that understanding the factors behind this influence can enhance the communication between the doctor and patient. 11 However, alternatively, if doctors do not have SM accounts, engaging in discussions via WhatsApp group can suffice as an alternative. Doctors who remain updated and maintain an active SM presence must be conscious that some colleagues may not have SM accounts.

2. Right Planning

Actively discuss current trends with other healthcare professionals

Cooperation in active correspondence about SM health-related issues is also significant, 11 and several non-governmental organizations (NGOs) discuss these matters on a regular basis. NGOs, particularly healthcare NGOs, serve as common platforms for dissemination of up-to-date information to the public via various platforms. 5 Discussions among different bodies consisting of both governmental organizations and NGOs that are usually held to discuss current issues and subsequently relay important information to the public by different mediums are mostly conducted through SM. For example, the Malaysian Ministry of Health has an official website to relay information to the public to avoid confusion and is regarded as a strong source of validated information. 18 This collection of endeavours helps to disseminate proper information and sends a strong, professional, united message to the masses.

3. Right Support

Maintain an online presence and support colleagues

An SM ‘influencer’ is an individual with a large following on SM and/or who is influential on one or multiple platforms. 19 The online community (collectively, ‘netizens’) take what influencers say rather seriously, sometimes to the degree of prompting immediate action; for example, an influencer may rapidly increase awareness on an issue and raise funds via crowdfunding. 20 Being a SM influencer or having an influential SM account may not be suitable for every primary care doctor, but supporting colleagues in their plight to educate the public will send a strong message on the importance of a certain issue and will help in halting the spread of false information. Even sharing and liking posts on SM can generate a positive effect. One reason why medical myths and pseudoscience remain popular among netizens is because of the strong and effective online presence of influencers, who are interactive with their audience and find unique, engaging ways to communicate. Even if a doctor does not have a great number of followers on their SM pages, making a statement on health-related issues will help their close friends and family understand the matter better. Doctors who may not be influencers still have the capacity to influence others, albeit at a smaller level; advocate proper health-related information; and become valuable assets to their communities. 21

Conduct further research

More research into this matter is required because how SM affects patients, particularly in primary care settings, is of utmost importance. Effective online communication by way of storytelling in real-life scenarios is one means by which people or organizations use SM to influence netizens, but future studies should investigate how SM affects health beliefs to promote good health behaviour. Without further analysis, the consequences may be detrimental, thereby complementing current ubiquitous problems such as unnecessary panic and ingestion of harmful substances thought to be preventative. 13 , 22

4. Right Model

Maintain professionalism, even online 23

Doctors should practice the code of professional conduct both in person and online, especially if patients are able to access their doctors’ SM accounts. Offensive language and prejudiced words easily backfire in online platforms, and the effects may reverberate offline. Even online, there are rules that all healthcare professionals with SM accounts should follow to garner respect from colleagues and patients alike.

Refrain from sharing patient information and stay general

Sometimes, doctors share information on SM in an effort to educate patients or share their experiences without realizing that they have breached confidentiality. Patients’ pictures (including documents such as X-rays) should only be uploaded with consent, 21 especially written consent. If a posted photograph features a patient, the eyes should be covered to protect the patient’s privacy. Doctors should be wary of exposing any form of patient identification, such as a patient’s location, name or identity number, and instead, they should use general language and either keep their patients anonymous or employ pseudonyms.

Avoid private consultations

It is common for doctors to field personal and private questions on health on their SM platforms. Because of the limitations of SM and its informal nature, proper consultation in clinical settings is safer for diagnosis and management of patients’ conditions. Formal online consultations should be via recognized mediums with strict standards of procedures. 21

SM plays an important role in disseminating information to the general public. Primary care doctors may be among the first healthcare contacts to validate or invalidate the healthcare information that they obtain. The main goal of doctors in primary care is to use SM to address health concerns, particularly about information that patients retrieve from SM; establish better communication; and improve health education. There are numerous challenges that primary care doctors face when using SM, but they may overcome the most salient challenges by implementing the optimal mindset, planning, support and model, as described above.

Acknowledgements

Conflicts of interest.