What do medical students and their clinical preceptors understand by primary health care in South Africa? A qualitative study

Mabuza and Moshabela BMC Medical Education https://doi.org/10.1186/s12909-023-04751-x (2023) 23:785 BMC Medical Education Open Access RESEARCH What do medical students and their clinical preceptors understand by primary health care in South Africa? A qualitative study Langalibalele Honey Mabuza1* and Mosa Moshabela2* Abstract Background The definition of Primary Health Care (PHC) issued by the World Health Organisation in 1978 indicated that essential health care should be made accessible to individuals and their communities close to where they live and work. In 1992 Starfield articulated the four pillars of PHC: the patient’s first contact with healthcare, comprehensive care, coordinated care and continuous care. Using this literature guidance, this study sought to explore what undergraduate medical students and their clinical preceptors understood by PHC in four South African medical schools. Methods A qualitative study using the phenomenological design was conducted among undergraduate medical students and their clinical preceptors. The setting was four medical schools in South Africa (Sefako Makgatho Health Sciences University, Walter Sisulu University and the University of KwaZulu-Natal and the Witwatersrand University). A total of 27 in-depth interviews were conducted among the clinical preceptors and 16 focus group discussions among the students who were in their clinical years of training (MBChB 4–6). Interviews were digitally recorded and transcribed verbatim, followed by thematic data analysis using the MAXQDA 2020 (Analytics Pro) software. Results Four themes were identified in which there were similarities between the students and their preceptors regarding their understanding of PHC: (1) PHC as the patient’s first contact with the healthcare system; (2) comprehensive care; (3) coordination of care and (4) continuity of care. A further two themes were identified in which these two groups were not of similar understanding: (5) PHC as a level or an approach to healthcare and (6) the role of specialist clinical preceptors in PHC. Conclusions Medical students and their clinical preceptors displayed an understanding of PHC in line with four pillars articulated by Starfield and the WHO definition of PHC. However, there remains areas of divergence, on which the medical schools should follow the guidance provided by the WHO and Starfield for a holistic understanding of PHC. Keywords Primary health care, First contact healthcare, Comprehensive care, Continuity of care, Coordination of care, Undergraduate medical students, Clinical preceptors, Generalists, Specialists *Correspondence: Langalibalele Honey Mabuza 1 School of Medicine, Clinical Integrated Programs, Sefako Makgatho Health Sciences University, 0012 Pretoria, South Africa 2 Research and Innovation, University of KwaZulu-Natal, 4001 Durban, South Africa © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Mabuza and Moshabela BMC Medical Education (2023) 23:785 Background In September 1978, in Alma Ata, the World Health Organisation (WHO) defined primary health care (PHC) as “the essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain … in the spirit of self-reliance and selfdetermination” [1]. It was also described as the first level of healthcare contact for individuals and their families, bringing healthcare to where people live, constituting the first element of a continuing healthcare process [1]. The “first level of contact” refers to the principle of the management of an undifferentiated patient. This is a call for healthcare practice and student training in all health sectors to emphasise first-contact patient presentation [2]. A “continuing healthcare process” addresses the follow-up care in patient management. Health care clinical preceptors and their students should engage on how to conduct follow-up care of all patients following the initial clinical encounter, their referral to other levels of care and their receipt when they are down-referred to the institutions that initially referred them [3]. In 1992 Barbara Starfield articulated four cardinal pillars of PHC, namely (1) first contact care, (2) continuity of care, (3) comprehensive and (4) coordination of care, [4] which she and other authors have since elaborated on to incorporate further principles, namely person and family centered, equitable, team based and collaborative, integrated, accessible and of high value [5–7]. In 2018, the WHO broadened the scope of PHC even further as a whole-of-society approach to health, incorporating health promotion, disease prevention, curative, rehabilitative and palliative care throughout the life of individuals and communities [8]. In light of the increasingly complex nature of patient wellness and community health due to factors such as global migration [9] and inequity of resources [10], the expansion of PHC as defined by WHO bears relevance on “comprehensive care,” which deals with the holistic approach to patient care, addressing the biomedical, psychological and social dimensions of health and well-being (bio-psycho-social) [2] and “coordinated care” which focuses on the macro level system integration, putting the individual needs at the heart of the system in order to meet the needs of the population, because “what is best for individuals within a population is [also] best for the population” [2]. The complexity of patient care requires that PHC extends beyond health care into social care, requiring interprofessional and intersectoral collaboration to meet this challenge. According to the WHO, interprofessional collaboration occurs when “multiple health workers from different professional backgrounds Page 2 of 14 work together with patients, familie (...truncated)