literature review of primary health centre

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Primary health care quality indicators: An umbrella review

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations MEDCIDS–Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS–Centre for Health Technology and Services Research, Porto, Portugal

Roles Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Affiliation USF Camélias, ACeS Grande Porto VII (ARS Norte)–Vila Nova de Gaia, Portugal

Roles Data curation, Formal analysis, Investigation, Writing – review & editing

Roles Data curation, Formal analysis, Investigation

Affiliation MEDCIDS–Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal

Roles Conceptualization, Formal analysis, Methodology, Writing – review & editing

Affiliations MEDCIDS–Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal, CINTESIS–Centre for Health Technology and Services Research, Porto, Portugal, Public Health Unit, ACeS Grande Porto VIII (ARS Norte)–Espinho/Gaia, Portugal

Roles Conceptualization, Writing – review & editing

Roles Formal analysis, Validation, Writing – review & editing

Roles Conceptualization, Formal analysis, Methodology, Resources, Validation, Visualization

Roles Conceptualization, Funding acquisition, Project administration, Resources, Supervision, Validation, Visualization, Writing – review & editing

• André Ramalho, 
• Pedro Castro, 
• Manuel Gonçalves-Pinho, 
• Juliana Teixeira, 
• João Vasco Santos, 
• João Viana, 
• Mariana Lobo, 
• Paulo Santos, 
• Alberto Freitas

• Published: August 16, 2019
• https://doi.org/10.1371/journal.pone.0220888
• Reader Comments

Nowadays, evaluating the quality of health services, especially in primary health care (PHC), is increasingly important. In a historical perspective, the Department of Health (United Kingdom) developed and proposed a range of indicators in 1998, and lately several health, social and political organizations have defined and implemented different sets of PHC quality indicators. Some systematic reviews in PHC quality indicators are reported but only in specific contexts and conditions. The aim of this study is to characterize and provide a list of indicators discussed in the literature to support managers and clinicians in decision-making processes, through an umbrella review on PHC quality indicators. The methodology was performed according to PRISMA Statement. Indicators from 33 eligible systematic reviews were categorized according to the dimensions of care, function, type of care, domains and condition contexts. Of a total of 727 indicators or groups of indicators, 74.5% (n = 542) were classified in process category and 89.5% (n = 537) with chronic type of care (n = 428; 58.8%) and effective domain (n = 423; 58.1%) with the most frequent values in categorizations by dimensions. The results of this overview of reviews are valuable and imply the need for future research and practice regarding primary health care quality indicators in the most varied conditions and contexts to generate new discussions about their use, comparison and implementation.

Citation: Ramalho A, Castro P, Gonçalves-Pinho M, Teixeira J, Santos JV, Viana J, et al. (2019) Primary health care quality indicators: An umbrella review. PLoS ONE 14(8): e0220888. https://doi.org/10.1371/journal.pone.0220888

Editor: Wisit Cheungpasitporn, University of Mississippi Medical Center, UNITED STATES

Received: March 18, 2019; Accepted: July 22, 2019; Published: August 16, 2019

Copyright: © 2019 Ramalho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files, and are from studies indexed and available in four databases (Medline, Scopus, ISI-WOS and CINAHL via Ebsco Host).

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was financed by FEDER - Fundo Europeu de Desenvolvimento Regional funds through the COMPETE 2020 - Operacional Programme for Competitiveness and Internationalisation (POCI), and by Portuguese funds through FCT - Fundação para a Ciência e a Tecnologia in the framework of the project POCI-01-0145-FEDER-030766 (“1st.IndiQare - Quality indicators in primary health care: validation and implementation of quality indicators as an assessment and comparison tool”).

Competing interests: The authors have declared that no competing interests exist.

Introduction

Primary health care (PHC) is defined by the World Health Organization (WHO) as the “essential health care based on scientifically sound and socially acceptable methods and technology, which make universal health care accessible to all individuals and families in a community. It is through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination" [ 1 ]. Some studies suggest that health systems with better financial and clinical results are those with a greater focus on PHC, thus enhancing the sustainability of the entire health system [ 2 – 4 ]. This depends on providing high quality primary health care, hence raising the need to develop methods for quality assessment and monitoring [ 5 ]. One of these methods is the use of quality indicators—a quantitative measure of the activities, that can assist as a guideline for quality monitoring and evaluation of relevant patient care and support services [ 6 , 7 , 8 ].

Quality of care was defined by the Institute of Medicine (IOM) in 1999 as the degree to which health services increase the likelihood of desired outcomes and are consistent with current professional knowledge [ 9 ]. The evaluation of the degree of quality of care is done through indicators, a set of measures that assist health care quality monitoring and evaluation in several areas, such as governance, management, assistance and support [ 10 , 11 ]. The importance of indicators is given by the fact that they allow for signalling opportunities of improvement, and controlling compliance with the best existing clinical practices, through quantitative parameters (planning, organizational, clinical) aiming better processes and outcomes [ 12 , 13 ].

Studies of how quality can be assessed were conducted by Donabedian and Fleming, who categorized the information from which inferences can be drawn on the topic, in three categories: structure, process and outcome [ 14 ]. The “three-part” assessment approach performed by the authors is only possible because a good structure increases the probability of a good health care processes, and good processes increase the probability of good outcomes [ 14 ]. Importantly, for a process to be a valid measure of quality, it must be closely related to a result that people care about [ 12 ]. It is also worth remembering that we often find factors that interfere with patients' survival and health-disease dynamics, and in these cases, it may be useful for outcome measures to be adjusted for other factors (such as lifestyle, disease) to control confounders that may affect the analysis of outcome indicators [ 10 ]. The development and selection of indicators must meet requirements for use, such as validity, reliability, relevance, pertinence, applicability, data availability, minimum bias, and moreover based on the best evidence available [ 15 , 16 ].

For historical contextualization only, the National Health Service Executive and the Department of Health in United Kingdom (UK)—pioneers in this area—proposed a range of indicators in 1998, many of which would apply to primary health care groups [ 17 ]. The interest in assessing the quality of primary health care services has increased, especially after 2004, when the Quality and Outcomes Framework (QOF) was introduced in the UK [ 18 – 20 ]. After the development of the QOF, some pay-for-performance systems have been developed over the years. These were based on the concept of allocative efficiency: “the optimal use of resources to achieve the intended outcomes” [ 21 ]. As such, financial incentive schemes are being used for PHC units worldwide and professionals, representing a way of rewarding improvements in productivity and/or adaptation to better quality healthcare provision [ 22 ].

Lately, several health, social and political organizations such as World Health Organization (WHO), Organization for Economic Cooperation and Development (OECD), European Commission and the Agency for Research and Quality of Health Care (AHRQ), have defined and implemented different sets of quality indicators for primary care [ 23 – 25 ]. There are several studies proposing PHC quality indicators in different countries, which have led to some systematic reviews revealing substantial geographical variability regarding quality of primary care services [ 26 ]. Identifying papers referring to PHC quality assessment projects, these systematic reviews reported that the number and content of indicators and their domains varied among studies. Moreover, they demonstrated that the lack of standardization of collection tools across projects would lead to invalid comparisons [ 27 – 31 ].

Considering the importance of understanding the PHC context, identifying and measuring quality indicators are essential factors for the achievement of high-quality care [ 32 ]. Some systematic reviews related to the topic are available in the literature but with focus on specific contexts, making it necessary to synthesize and understand the reality of these indicators in a broader scope. The aim of this umbrella review is not an exercise for a meta-review, but rather to identify systematic reviews of studies on quality indicators (QI) for PHC to provide a list of selected indicators considered in systematic reviews.

An umbrella review was conducted, to collect and extract data from all systematic review studies uncovering PHC quality indicators. The methodology was performed according to PRISMA Statement [ 33 ] ( Fig 1 and S1 File ). All the phases were performed by two independent reviewers with a third as a tie-breaker, considering the eligibility criteria. Composing PICO, participants were the primary care systems and the intervention to be analysed is the implementation of quality indicators. The comparator was the categories such as context, dimension, type and domain of care, and the main outcome was the primary health care quality indicators to present a summary list of the indicators used in PHC. The protocol was registered at PROSPERO [ 34 , 35 ] with number CRD42019124170 ( S2 File ).

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https://doi.org/10.1371/journal.pone.0220888.g001

Search strategy

Identification phase..

From an initial set of studies, a search expression was defined and calibrated [ 36 , 37 ] through test rounds for each and combined terms in electronic databases. The search database eligible for calibration was MEDLINE. There were no restrictions on publication period or language. We considered studies from inception until 20 th December 2018, the date when the search was performed. After the calibration, the most relevant search expression ( S3 File ) was used in four databases (MEDLINE, Web of Science, Scopus and CINAHL plus via EBSCOhost). The terms related to systematic reviews were chosen using information of balance between sensitivity and specificity terms, available in the literature [ 38 – 42 ].

Study selection

Eligibility criteria..

Included studies 1) are systematic reviews regardless of their objective or nature (including studies that have used a formal systematic review as their starting point) 2) have a primary health care scope and 3) aim at quality indicators assessment or development. We excluded studies that 1) did not have an abstract in the screening phase or 2) which, in the eligibility phase, did not have the full-text version available, even after direct contact with the author.

Screening phase.

Once we obtained all the articles, duplicate between databases were identified and excluded using Endnote. From 2817 articles, a total of 1480 remained after removing the duplicates and were evaluated in the screening phase (reading of title and abstracts) by two independent reviewers and a third as a tie-breaker.

Eligibility phase.

Full-texts of all the included articles were extracted (n = 33). As it was planned to contact the corresponding author if the full text of the article was not available, we used the ResearchGate website to extract full text articles, or to contact the authors for the articles that were not available. All eligible articles were assessed in full text format. The eligibility criteria were reapplied by two independent reviewers and a third as a tie-breaker, and the reference lists of each eligible article were scrutinized for any omitted studies.

Quality assessment and risk of bias.

The evaluation of the quality and risk of bias of the eligible systematic reviews was carried out by evaluation through AMSTAR-2 tool [ 43 ]. The disagreement between the reviewers was solved by consensus in an agreement meeting by three reviewers. The AMSTAR-2 tool was considered for the definition of quality classification, fulfilling the systematic review research model. Articles that meet AMSTAR-2 requirements have been classified as "HIGH"; those that did not meet up to 2 relevant requirements were classified as "MODERATE", and those with more than 2 requirements not appraised were classified as "LOW". This quality assessment was carried out in order to understand how the studies were conducted and how the indicators were selected. However, none of the selected articles were excluded based on this assessment because the objective of this umbrella review does not include results from implementation of indicators, only a list of indicators implemented. The AMSTAR-2 items #11 and #12 were not applicable to the studies.

Data collection process.

In first stage, a standard data extraction form was created, and general data extracted from each study included the following characteristics: article title, name of first author, publication type, country of origin, year of publication and indicators identified in the studies. Three reviewers independently extracted the data. Differences in data extracted was resolved by consensus method.

A second stage consisted in abstracting information regarding quality indicators using the primary studies in the systematic reviews included. This was necessary since some indicators identified in the systematic reviews lacked a proper description. Finally, indicators duplicated were identified by the reviewers involved in the first and second stage of data extraction and excluded through consensus.

Synthesis analysis.

Analysis of the indicators were carried independently by two reviewers and third as a tie-breaker, who categorized the indicators presented in the systematic reviews included, according to five classifications frameworks: Context reflects the WHO ICPC-2 chapters categorization (General and Unspecified; Blood, Blood Forming Organs and Immune Mechanism; Digestive; Eye; Ear; Cardiovascular; Musculoskeletal; Neurological; Psychological; Respiratory; Skin; Endocrine/Metabolic and Nutritional; Urological; Pregnancy, Childbearing, Family Planning; Female Genital; Male Genital; Social Problems) [ 44 ]; the dimensions of care was defined based on the framework proposed by Donabedian to assess quality of healthcare (structure, process and outcome)[ 10 , 14 ], type of care reflects whether an indicator is associated with acute, chronic, or preventive care [ 10 , 45 ]; function of care conveys information about the purpose of health care (screening and prevention, diagnosis, treatment, follow up and continuity) [ 10 , 45 ] and domains and domain of health care quality was defined based on the framework proposed by National Academy of Medicine (NAM)(former Institute of Medicine) in 2001 (safe, effective, efficient, timely, patient-centred, equitable)[ 9 ].

Frequencies were computed based on these frameworks to analyse and summarize the information extracted, in two perspectives: Indicators by Context and Dimensions of care; and Type, Function and Domain by Dimensions of care.

Search and study selection

The identification phase results returned 2817 articles (being 419 MEDLINE, 1452 Scopus, 567 ISI-WOS, 379 CINAHL via EBSCOhost). After removal of duplicate articles our research started with 1480 articles. Title and abstract were scrutinized for relevance based on inclusion and exclusion criteria. From a total of 1401 excluded articles, 1332 did not meet the eligibility criteria and 69 had no abstract available. The eligibility phase started with 79 articles that were read in their full-text versions, checking for the eligibility criteria. The studies identified by that involved RAND methodology, their inclusion in the umbrella review was justified since the methods included an initial systematic review prior the implementation of a panel discussion for validating appropriateness of indicators. Since the goal was to be as inclusive/comprehensive as possible, these studies were also included. In the perspective of the authors, the exclusion of these studies could compromise comprehensiveness of the umbrella review. The excluded studies (n = 46) did not have a full text version available or did not meet the eligibility criteria. Thirty-three articles were selected [ 29 , 30 , 46 – 77 ], for qualitative analysis and for the quality and risk of bias assessment. ( Fig 1 )

The Quality and Risk of Bias Assessment was carried out using the AMSTAR-2 assessment tool [ 45 ]. This assessment performed by the reviewers classified the confidence rate of each review as "low" (n = 14), “moderate” (n = 17) or “high” (n = 3) ( S4 File ).

Among the studies with low overall confidence rate, the main points of non-compliance with the requirements were, the non-performance of adequate studies selection with no extraction in duplicate (at least two independent reviewers); studies presented the quantity of excluded articles but without proper justification; not considering risk of bias (RoB) in individual studies when interpreting / discussing the results of the review; not using a satisfactory technique to assess RoB in individual studies that were included in the review and did not provide a satisfactory explanation for, or discussion of any heterogeneity observed in the results.

Study characteristics.

The 33 articles in this umbrella review included articles from Canada (n = 5), Spain (n = 5) and the United Kingdom (n = 5), among other countries ( Fig 2 ).

https://doi.org/10.1371/journal.pone.0220888.g002

Although the diversity of countries where the systematic reviews were performed, all articles were evaluated in the English version, except article #16 (Spanish).

The reviews comprised a total of 1406 included primary studies and 21 national guidelines, The databases used to search for these articles were the most varied, with the most used databases: MEDLINE (100%) and EMBASE (70%) ( Table 1 ). Seven hundred and twenty seven (n = 727) indicators were extracted from the systematic reviews and primary studies in the reviews (Supplementary Material S1 Appendix ) .

https://doi.org/10.1371/journal.pone.0220888.t001

The dimension of care with the highest number of indicators by context was process (n = 548, 74.5%), followed by outcome (n = 146, 20.0%) and structure (n = 46, 6.0%). The frequency of indicators among the classification by dimension of care and condition contexts is shown in Table 2 . When analysed by dimension of care and condition context, the indicator totals within each dimension (columns) could not be added up because there were indicators (n = 13) that participate in more than one context category within each dimension of care. The total number of indicators analysed was the denominator of the percentage in parentheses and refers to the total number of indicators in the extraction list (n = 727) indicated in the heading. The same is observed in context totals (lines). The ranking of the highest number of indicators found were classified in the categories A—general and non-specific followed by the K—Circulatory System categories specific, P–Psychological and R—Respiratory System. The categories B—Blood, hematopoietic and lymphatic organs, H—Ears and Z—Social Issues, had no indicators presented in the included studies.

https://doi.org/10.1371/journal.pone.0220888.t002

Among the indicators of structure (n = 45), the indicators with the most frequent type of care were those classified in all three categories—Acute, Chronic and Preventive (n = 34, 45.3%), e.g. Professional profiles; Primary care expenditures; Availability of primary care services. Those of specific category of type of care were less frequent ( Table 3 ).

https://doi.org/10.1371/journal.pone.0220888.t003

Structure indicators were more commonly assigned to more than three functions of care (n = 35, 77.7%) (Diagnosis, Screening and Prevention, Follow-up and continuity, Treatment), eg Availability: Number of physicians per unit of population; Availability: Number of hospital beds per unit of population; Technical efficiency.

Most structure indicators were associated with the effective domain of health care quality (n = 22, 48.8%) e.g. Governance: (From) centralization of primary care management and service development; Integration of primary care in the health care system; Appropriate technology in primary care. No structure indicators was associated with the safe domain of health care quality.

Among the indicators of process (n = 542), Chronic care was the most frequent type of care observed (n = 355, 65.5%), e.g. Comorbid psychiatric conditions and response to treatment; Follow-up contacts during treatment episode after initial evaluation; Comprehensive diabetes care: HbA1c testing. Preventive care (n = 88, 16.2%) and all types of care (n = 80, 14.7%) shared similar frequencies ( Table 4 ).

https://doi.org/10.1371/journal.pone.0220888.t004

Treatment was the most frequent function of care of the process indicators (n = 254, 46.8%), e.g Tranquilisers prescribed: % of the recommended; Possible contraindications should be taken into account when antibiotics are prescribed; Co-prescription of itraconazole with simvastatin, or with atorvastatin at a dose ≥80mg. Screening and prevention and Follow up and continuity were also common, associated with 111 indicators each. Examples of Screening and Prevention indicators are: Pap smear rate; Urinary incontinence during initial dementia evaluation; Preventive care Immunizable conditions; Medical attention for nephropathy; and of Follow up and Continuity: Follow up by the same clinician; Plan for follow up care explained and scheduled; Extra pyramidal effects monitoring; Percentage of patients with asthma and measures of variability or reversibility recorded. Most process indicators were also associated with the effective domain of health care quality (n = 310, 57.2%) e.g. Follow-up contacts during treatment episode after initial evaluation; Coordinated care; Asthma: Percentage of children with follow-up from the same doctor for at least 80% of their visits. Also a common domain of health care quality in the listing was Safe (n = 152, 28%), e.g. Detection of Falls; Polyfarmacy; Systemic Lupus Erythematosus: Discussion about teratogenic risks of medication.

Among the indicators of Outcome (n = 140), Chronic care was the most frequent type of care observed (n = 67, 47.8%), e.g. Absenteeism from Work/School for Asthma; Proportion with increased BMI / abdominal waist line; Prevention of pressure ulcers in patients included in the chronic dependent patients care program; Duration of untreated psychosis. The frequency of indicators regarding acute care only (n = 51, 36.4%) and preventive care (n = 44, 31.4%) were similar ( Table 5 ).

https://doi.org/10.1371/journal.pone.0220888.t005

Treatment was the most frequent function of care within outcome indicators (n = 57, 40.7%), e.g Sedation side effects; Number of deaths in seven days between those whose calls were handled by doctors or nurses. Screening and Prevention (n = 25, 17.8%) and Diagnosis (n = 22, 15.7%) followed with similar number of outcome indicators. Examples of Screening and Prevention indicators are: Quality of maternal and child health care: maternal mortality rates; Quality of health promotion: Smoking rate; Preventive care: Low birth weight rate.

Finally, most outcome indicators were associated with the effective domain of health care quality (n = 91, 65%) e.g. Potentially preventable hospitalisation clinical indicator of Chronic Obstructive Pulmonary Disease; Comorbid psychiatric conditions and response to treatment. Also, a common health care quality domain in the listing was Patient-centered (n = 26, 18.5%), e.g. Patients with multiple chronic conditions and medications attended in primary care; Patient Quality of Life; Patient satisfaction with the family physician/specialist coordination of care.

Primary health care (PHC) is where the patient's first contact with the health system occurs and comprises a range of actions which includes many dimensions, domains, and contexts [ 14 ]. Due to these characteristics, it becomes important to evaluate and monitor the quality of primary care [ 78 – 80 ]. It is established that primary care can lead to better health outcomes, lower costs, and greater equity in health [ 81 ] and this can be achieved by using QIs, a set of objective measures with clinical evidence [ 6 , 82 – 83 ] that can represent an acceptable standard of care across a specific patient population [ 84 ].

As the aim of this umbrella review of systematic reviews was to search indexed literature, in order to find a setlist of QI useful for monitoring quality in PHC, our study shows interesting answers to what was proposed, identifying 33 systematic reviews of studies on quality indicators in primary health care and providing a list of selected indicators considered in the included reviews. The study resulted in 727 quality indicators, which were later categorized by context, dimension, type of care, function and domain.

Context of care was classified according to the International Classification of Primary Care (ICPC-2), which is recommended by the World Organization of Family Doctors (WONCA) for codification in this level of care.[ 44 ]. Although practical and useful for primary care, this classification represents a simplification and attempt at uniformization with other classification systems such as the International Classification of Diseases (ICD-11), which is not achieved completely [ 85 ]. Furthermore, since ICPC-2 is a classification based primarily in the location of the symptoms or disease, the authors could not define the context for 100 indicators, since they relate mostly to organizational measures not contemplated in adopted system. “Not defined” was the fourth most common context, representing 13.8% of the total of indicators found.

The majority of the indicators belong to the context category “A–General and Unspecified” (n = 112, 15.4%), which may reflect an attempt at creating indicators applicable to a wide range of procedures and contexts. Circulatory, psychological, respiratory, musculoskeletal and endocrine/metabolic diseases are the next most frequent contexts, indicating also a bigger concern for areas which are more prevalent in primary care (see Table 2 ) .

Most of the indicators found by the authors were related to the dimension of Process (n = 542, 74.5% of total). As defined by Donabedian, this dimension focuses in what is actually done, such as patient’s procedures in seeking care and practitioner’s activities while providing it [ 14 ]. Since QIs represent an opportunity for improvement in areas where quality standards are not met, process indicators may help implementing better procedures and guidelines, resulting in better health care. Outcome dimension was the second most frequent dimension (n = 140, 19.2%); since healthcare outcomes depend on the care provided, these indicators evaluate the result of the course of action of PHC professionals, unlike process indicators which evaluate a single aspect of care.

Type of care

Type of care was classified as acute, chronic or preventive, with “Chronic” being the most frequent. Indicators focused on chronic care are very helpful, since family doctors follow their patients longitudinally for many years, monitoring and managing the chronic diseases they develop throughout their lives [ 79 ]. The management and control of chronic conditions/diseases in the population is one of the main focuses of the activities of primary health care, being also the most studied and evaluated by the QIs, as our study demonstrates. Indicators such as control of prescriptions and monitoring of diseases such as asthma, COPD, hypertension and diabetes, as well as indicators of ambulatory care sensitive conditions that can generate avoidable hospitalizations are part of the list of indicators presented [ 30 ].

Indicators relating to “Treatment” were the most frequent, followed by “Screening and Prevention” and “Follow-up and Continuity”. Once again, the results mirror important aspects of PHC. The consideration of the patient as a whole and the approach of disease in a holistic perspective imply that the healthcare provider must consider indications, potential adverse effects and comorbidities of each patient before elaborating a treatment plan [ 79 ]. Within outcome indicators, most these were focused on treatment, contributing to the evaluation of its complications and preventable hospitalizations, once again alerting providers to re-evaluate their patients and review therapeutic options.

Regarding “Screening and Prevention”, the prevention of disease as well as early diagnosis are the main focus of this level of care [ 1 ]; the development of screening programs for oncological conditions and adequate follow-up for prevention of complications contribute to better health care in this aspect.

“Effective” was the most common domain among the three dimensions of care. Indicators under this domain focus on the capacitation of PHC providers and their articulation with secondary care. Since the effectiveness of a health system depends on the quality of its primary care [ 29 , 86 ], it would be expected that this would be an area of interest.

Other domains such as “Patient-centered” or “Safety” were also commonly evaluated through QIs, demonstrating once again the concern for a holistic approach of PHC.

Limitations

Although there is a significant amount of literature on health quality indicators, some of them are not directly linked to PHC, making it difficult to extrapolate the conclusions of the QI that are applied mainly to the secondary and tertiary levels of attention. Most articles published on QIs in PHC tend to choose very limited and specific areas of health care, without a generic approach to PHC as a whole. The uniqueness and heterogeneity found in these studies show the importance of comprehensive systematic reviews on PHC.

Systematic reviews included in this paper selected primary studies using slightly different methodological assessment and statistical pooling; some of these articles did not discriminate how many primary studies were included in the analysis. The use of different databases in each systematic review and different methods for choosing search terms, calibration and specificity of the search expressions must be considered when interpreting the results.

The authors of this article have searched the primary studies included in each systematic review in order to obtain a list of PHC quality indicators. The lack of a uniform method to collect and present the QIs among the included reviews limited the ability to withdraw complete information from every paper. As an example, most studies were missing information regarding the numerator, denominator and calculation method for each QI.

Conclusions

This is, to the best of our knowledge, the first umbrella review focusing on QIs for primary healthcare in a border scope. We present a final list of indicators ( S1 Appendix supplementary material ) from eligible systematic reviews summarizing the indicators available in the literature, allowing us to understand which areas of primary care are better covered by these measures. The results of our umbrella review are valuable and imply the need for future research and practice regarding quality indicators, as a great opportunity for further studies to test the acceptability, feasibility, reliability, comparison tools and validity of those indicators, while also checking for problems with their implementation to PHC, with adequate information and registration systems. It also provides a ready way for clinicians, managers and health decision makers to gain a clear understanding of the most evidence-based publications related to PHC quality indicators.

Supporting information

S1 file. prisma statement checklist..

https://doi.org/10.1371/journal.pone.0220888.s001

S2 File. PROSPERO protocol register.

https://doi.org/10.1371/journal.pone.0220888.s002

S3 File. Search expression query.

https://doi.org/10.1371/journal.pone.0220888.s003

S4 File. Quality and risk of bias assessment.

https://doi.org/10.1371/journal.pone.0220888.s004

S1 Appendix. Supplementary material–indicators list.

https://doi.org/10.1371/journal.pone.0220888.s005

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Primary health Centres' performance assessment measures in developing countries: review of the empirical literature

Affiliations.

• 1 Department of Primary Care, CAPHRI, Maastricht University, Maastricht, The Netherlands. [email protected].
• 2 , Present address: No 18, 3rd Main, 1stCross, Navodaya Layout, Shakambari Nagar, Sarakki, J P Nagar 1st Phase, Bengaluru, Karnataka, 560070, India. [email protected].
• 3 Department of Social Medicine, research institute CAPHRI, Maastricht University, Maastricht, The Netherlands.
• 4 Institute of Health Management Research, Bangalore, India.
• 5 Department of Health Ethics and Society, research institute CAPHRI, Maastricht University, Maastricht, The Netherlands.
• 6 Department of Primary Care, CAPHRI, Maastricht University, Maastricht, The Netherlands.
• PMID: 30092842
• PMCID: PMC6085632
• DOI: 10.1186/s12913-018-3423-0

Background: It is universally accepted that primary healthcare is essential for achieving public health and that assessment of its performance is critical for continuous improvement. The World Health Organization's (WHO's) framework for performance assessment is a comprehensive global standard, but difficult to apply in developing countries because of financial and data constraints. This study aims to review the empirical literature on measures for Primary Health Centre (PHC) performance assessment in developing countries, and compare them for comprehensiveness with the aspects described by the WHO Framework.

Methods: Research articles published in English scientific journals between January 1979 and October 2016 were reviewed systematically. The reporting quality of the article and the quality of the measures were assessed with instruments adapted for the purpose of this study. Data was categorized and described.

Results: Fifteen articles were included in the study out of 4359 articles reviewed. Nine articles used quantitative methods, one article used qualitative methods exclusively and five used mixed methods. Fourteen articles had a good description of the measurement properties. None of the articles presented validity tests of the measures but eleven articles presented measures that were well established. Mostly studies included components of personnel competencies (skilled/ non-skilled) and centre performance (patient satisfaction/cost /efficiency).

Conclusions: In comparison to the WHO framework, the measures in the articles were limited in scope as they did not represent all service components of PHCs. Hence, PHC performance assessment should include system components along with relevant measures of personnel performance beyond knowledge of protocols. Existing measures for PHC performance assessment in developing countries need to be validated and concise measures for neglected aspects need to be developed.

Keywords: Developing countries; Performance assessment; Primary health centres.

Publication types

• Research Support, Non-U.S. Gov't
• Developing Countries
• Empirical Research
• Outcome and Process Assessment, Health Care* / methods
• Outcome and Process Assessment, Health Care* / standards
• Primary Health Care / organization & administration*
• Public Health
• Quality Indicators, Health Care
• Quality of Health Care / standards
• World Health Organization

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• Volume 3, Issue Suppl 3
• How context affects implementation of the Primary Health Care approach: an analysis of what happened to primary health centres in India
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• http://orcid.org/0000-0001-8257-3985 Sudha Ramani 1 ,
• Muthusamy Sivakami 2 ,
• Lucy Gilson 3 , 4
• 1 Tata Institute of Social Sciences , Mumbai , India
• 2 School of Health Systems Studies , Tata Institute of Social Sciences , Mumbai , India
• 3 University of Cape Town , Cape Town , South Africa
• 4 London School of Hygiene and Tropical Medicine , London , UK
• Correspondence to Sudha Ramani; sudha_ramani{at}yahoo.com

Introduction In this paper, we elucidate challenges posed by contexts to the implementation of the Primary Health Care (PHC) approach, using the example of primary health centres (rural peripheral health units) in India. We first present a historical review of ‘written’ policies in India—to understand macro contextual influences on primary health centres. Then we highlight micro level issues at primary health centres using a contemporary case study.

Methods To elucidate macro level factors, we reviewed seminal policy documents in India and some supporting literature. To examine the micro context, we worked with empirical qualitative data from a rural district in Maharashtra—collected through 12 community focus group discussions, 12 patient interviews and 34 interviews with health system staff. We interpret these findings using a combination of top–down and bottom–up lenses of the policy process.

Results Primary health centres were originally envisaged as ‘social models’ of service delivery; front-line institutions that delivered integrated care close to people’s homes. However, macro issues of chronic underfunding and verticalisation have resulted in health centres with poor infrastructure, that mainly deliver vertical programmes. At micro levels, service provision at primary health centres is affected by doctors’ disinterest in primary care roles and an institutional context that promotes risk-averseness and disregard of outpatient care. Primary health centres do not meet community expectations in terms of services, drugs and attention provided; and hence, private practitioners are preferred. Thus, primary health centres today, despite having the structure of a primary-level care unit, no longer embody PHC ideals.

Conclusions This paper highlights some contextual complexities of implementing PHC—considering macro (pertaining to ideologies and fiscal priorities) and micro (pertaining to everyday behaviours and practices of actors) level issues. As we recommit to Alma-Ata, we must be cautious of the ceremonial adoption of interventions, that look like PHC—but cannot deliver on its ideals.

• primary health care
• peripheral health clinics
• health policy and systems research
• contextual factors

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjgh-2018-001381

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Key questions

What is already known.

Experience since the Alma-Ata declaration has shown that implementing the espoused vision of Primary Health Care (PHC) is not straightforward, despite global commitment.

What are the new findings?

This study highlights some of the challenges posed by contexts to the implementation of the PHC approach through the example of primary health centres in India.

Primary health centres were originally envisaged as ‘social models’ of service delivery; frontline services close to the homes of people, that consider people’s needs, integrate preventive and curative care and link to specialty care when required. But historical macro and micro contextual issues have led to primary health centres that only look like a PHC intervention, but in reality, are far removed from its philosophy.

What do the new findings imply?

Contextual constraints can result in interventions (like the primary health centres we studied) that merely look like PHC; but do not embody its spirit.

Macro (pertaining to ideologies and fiscal choices) as well as micro (pertaining to norms and day-to-day behaviours of actors) contexts can pose challenges to the implementation of the PHC approach; hence, constraints at both levels need to be addressed.

Global rhetoric on health has recently showed a renewed interest in the values and practices of comprehensive Primary Health Care (PHC). The adoption of the Sustainable Development Goal of ‘healthy lives’ and ‘well-being for all’ marks a change towards more holistic considerations of health; in line with the sociopolitical ideas of PHC heralded 40 years ago at the Alma-Ata conference. 1 2 Some of these ideas have been reaffirmed recently in global forums. 3 4 However, there is an urgent need for these ideas on PHC to take roots within country contexts—for past experience has shown that implementation of PHC is not straightforward. At a macro level, a whole range of factors in a country’s health system context-competing ideologies to the PHC approach (global and country-specific), fiscal priorities and development aid mechanisms that favour vertical programs—along with broader sociopolitical and epidemiological factors—influence the uptake of PHC interventions. 5–7 Further, these macro issues interact with the ‘everyday politics’ of the health system 8 —more specifically, front-line actors’ values, past experiences and expectations. 9 10 All this together influences what happens to PHC on the ground.

We elucidate some challenges posed by contexts to the implementation of PHC using the example of primary health centres in India, a rural peripheral health unit within the public health system ( figure 1 ). These centres were originally visualised in the 1940s as a ‘social model’ of health service delivery—frontline services close to the homes of people, that consider people’s needs, integrate preventive and curative care and link to specialty care as needed. 11 The Alma-Ata declaration gave impetus to the expansion of these centres within the country. 12 However, today’s primary health centres are a far cry from what was envisaged originally. These centres are fraught with several infrastructural weaknesses, 13–15 no longer serve as ‘first access institutes’ for the community—who rely mainly on local private practitioners 16 17 and deliver barely 15% of primary-level services. 18

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Rural public health system in India.

In this paper, we analyse what happened to primary health centres in India. First, we present a brief historical review of ‘written’ policy in India—to understand macro level policy choices—and some of the drivers of these choices—that have shaped primary health centres (the ‘macro context’). Then, we use a contemporary case study of primary health centres from one rural area—to delineate some of the ground-level issues at these centres (the ‘micro context’)—focussing on the norms, practices and expectations of the community and providers at primary health centres. Together, an account of these contexts illustrates some of the complexities in implementing PHC.

Policy implementation processes have been recognised as being shaped by complex interactions between actors, processes and contexts. 19 20 Multiple notions of ‘context’ exist in literature. Context has been considered as factors beyond the health sector 21 ; as having distinct dimensions—situational, structural, cultural and external 22 ; and as a source of ‘power’ that underpins policy-makers choices. 23 In this study, context mainly refers to factors—at macro levels and micro levels of the health system—that have influenced primary health centres.

Examining macro contexts

By macro contexts, we refer to ideologies and fiscal choices (mainly national, but these reverberate with global issues) that have shaped primary health centres in India. We focus on factors that contributed to the originally envisaged model of primary health centres—and subsequent policy choices—influenced by competing ideologies and fiscal priorities—that attenuated this model.

To examine macro contexts, we conducted a historical literature review of 13 national-level policy documents (online supplementary table 1 ), 5-year national economic plans since independence in 1947 and some supporting literature on the development of Indian health policies (The account of the macro context of primary health centres presented in this paper has been derived from a literature review of key policy documents in India, supported by global literature and research on history of public health in India. Some of this narrative has been derived from a larger discourse analysis of Indian policy documents to trace the history of primary health centres and their policy content in India. This analysis focused on ideational contexts that shaped and framed policies in particular ways, rather than others. This larger discourse analysis is not a part of this paper.). The policy documents we examined were not treated as ‘self-evident’ but as products of broader sociocultural thinking, that endorsed certain ideologies and provided explanations for recommended actions. 24 Some of these explanations have been presented through illustrative policy quotes ( table 1 ). The Indian authors used their familiarity with the history of Indian health policy to generate an initial list of documents for the review; and this list was vetted by three national experts—one from academia, one ex-policy-maker and one civil society member. These experts also offered suggestions on a summarised narrative. While the focus of the review was on national policies, we drew on some global documents suggested by the experts; and ones mentioned in the Indian policies explicitly. We have presented the review as a historical narrative.

Supplemental material

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Illustrative quotes from Indian policy documents

In addition to the national macro context, we briefly reviewed the history of health development in Maharashtra ( box 1 )—the state where we conducted our case study. This is because, in India, health is a shared responsibility between the federal and state governments; while national policies set goals and fund priority programmes, states fund a major portion of other health activities. 25 Hence, the state context—overall development status, health priorities and administrative structures—also influences PHC on the ground.

Maharashtra context

Maharashtra is the third largest state in India, considered as one of the more economically advanced states in the country. It performs better than India’s average on indicators such as Crude Birth Rate (15.9, India: 20.4), MMR (68 per 100000, India: 167 per 100000) and IMR (19 per 1000 live births; India: 34 per 1000 live births). 69 As of March 2017, it has 1814 primary health centres, covering a population of 33 934 people (as per norm to cover 30 000 people). 70

The following features of the health system can be considered as important in shaping PHC in Maharashtra:

Increasing privatisation: Post structural adjustment policies in the 1990s, state government expenditure on health has decreased as per cent of National State Domestic Product. 71 In 2015–2016, total state expenditure on health was about 0.6% of GDSP, and lower than other states like Karnataka=0.69, Tamil Nadu=0.74 and Kerala=0.93 72

‘Well-functioning’ primary health centres: The state has a good network of primary health centres, that rank above Indian average in terms of human resource availability (Filling rural doctor posts has been an important challenge in many states). 70 Maharashtra is considered as one of the five ‘high production’ states-for human resources for health 53 ; the state has 52 medical colleges of which 23 are public. 73 Policy dictates a 1-year compulsory rural service stint for undergraduate medical students from public colleges and that, to some extent, fills vacancies at primary health centres temporarily. 74

Primary health centres as ‘public health’: In the public health sector of Maharashtra, at district level—the line of authority for ‘ public health’ (primary health centres and below) and ‘ clinical care’ (tiers above primary health centres) are independent. 71 75 The development of primary health centres that come under ‘public health’—has been integrated with the local self-government architecture since 1961; this move has been said to have brought about early expansion of these centres in the state—in comparison to the rest of the country. 71

In summary, despite having comparatively good infrastructure and human resources in the public sector, utilisation patterns in Maharashtra show a clear preference for the private sector. One analysis of national surveys (2014) found that—for ambulatory care, only 7.5% of people used primary-level tiers (India: 8.5%); 10.4% used the public hospital (India:17%) and the rest used private health care. 76

Examining the micro context

Micro-level contexts, in our study, encompass local actors’ values, expectations and practices. By actors, we refer to both community and health system actors. Frontline workers use their discretion to understand, cope and fit a policy idea into their routine behaviours (termed as ‘practices’); and it is these practices of frontline workers that the community ultimately experiences as policy. 10 26 This, in turn, affects community expectations from primary health centres and their utilisation. In other words, how local actors interact with a policy idea can be considered as the ‘pragmatic context’ of policy implementation. 9

For examining micro contexts, we collected empirical data from a rural area in Maharashtra, that had a mix of primary health centres with good and poor infrastructure—as per national quality standards. 27 We interacted with both health system staff and the community. Twelve Focus Group Discussions (FGD) were held in the catchment area of seven primary health centres with three only women’s groups, one men’s group and eight mixed groups (We had some concerns about having only mixed group FGDs; and hence, we conducted a few FGDs separated by gender. But mixed groups in this setting seemed to work as well.) With the community, we discussed generic health seeking notions; and interactions and expectations pertaining to primary health centres. We interviewed 12 patients from three primary health centres to understand why they had chosen to access these. We also conducted In Depth Interviews with health system actors—administrators, doctors, nurses and other support staff at primary health centres—to understand their experiences and expectations (15 doctors, 10 nurses, 5 support staff and 4 senior level staff). The above data were collected by the first author, with assistance from the Centre for Social Medicine, Pravara Institute of Medical Sciences (Four interns helped with data collection, but the first author was a part of all interviews and 10 FGDs. The interns did two FGDs independently).

Data were collected in local language between April and September 2018—in four iterations—with data analysis happening simultaneously. All recorded FGDs and interviews were transcribed and translated to English. Transcripts were coded inductively through an iterative process to bring out key challenges in the micro context. 28 29 In analysing the data, we followed the three steps described by Miles and Huberman 28 : (1) Data reduction—in which codes were affixed to blocks of texts; some themes were based on the tools, but many concepts emerged from the data (2) Data display—data were further condensed systematically in three categories: doctors, support staff and the community (3) Drawing conclusions—here, we examined condensed data across all categories to draw inferences on the ‘micro context’. NVivo V.12 was used to aid the coding process. The first author led the analysis, but preliminary summaries were shared with the others. During the last iteration of data collection, these summaries were shared with two doctors and with the community during the last two FGDs for validation.

Interpreting the macro and micro contexts together

We examined two levels of context—macro and micro—since dismissing either of these would paint a partial picture: examining only the macro issues would discount local actor values and practices; and examining only the micro issues would ignore the broader policy context. This type of multilevel approach to studying context has been used previously—though studies have mostly looked at three contextual levels—macro, meso and micro. 30 31 We looked at only two levels as the boundaries between the ‘meso’ (health facility level) and the ‘micro’ (the individual level) often blurred in the empirical data. Hence, we grouped everything that defined the ‘pragmatic context 9 ’ at primary health centres—local values, practices of the community and the health system—under ‘micro contexts’.

To interpret the macro and the micro contexts together, theory offers two broad understandings of policy processes—‘top–down’ and ‘bottom–up’. From a top–down perspective, clear consistent and well-planned policies in a supportive environment lead to successful implementation 32 ; in this line of thinking, the starting point of interpretation is the policy on PHC adopted (or not) at national and subnational levels, which has consequences that manifest at micro-levels of primary health centres. From a bottom–up perspective, primacy is given to ‘agency’ and ‘discretion’ among frontline health workers 9 10 26 ; in this line of thinking, the attitudes and behaviour of actors in the frontline based on their norms, values and practical realities—influences PHC implementation. In this paper, we present the ‘macro’ and the ‘micro’ context separately; and in the discussion, we interpret these findings using both top–down and bottom–up perspectives.

We took written consent from all community participants who could read and write (from a few who could not, we took verbal recorded consent). Consent from health system participants was mostly written; four doctors were not comfortable signing the consent form—we obtained only verbal consent from them. When given permission to record, these interviews were audio recorded. All recordings have been deleted after transcription. All transcript data has been anonymised; and we have not mentioned the name of the district or of particular health centres—in order to protect the health system staff. Permissions for the study were taken from state-level authorities.

Patient and public involvement

The case study in Maharashtra examined community perspectives on primary health centres. For this, we orally discussed with the community and some outpatients at primary health centres about their experiences and expectations from these centres. The community/patients were not involved in the study design—and we will not be able to disseminate the study results to them.

The macro context of primary health in India: a historical review

Pre-independence.

Many of the core principles of the PHC approach are emphatically defended in the first visionary document of India’s health system—the Bhore committee’s report (1946) 11 including ideas of universality (‘no individual should fail to secure adequate medical care due to inability to pay’), health as development and the need for easy access to basic care, that integrates the preventive and the curative ( table 1 , quotes 1.1, 1.2). The report visualises a health system in India with a strong public sector presence that provides comprehensive care to all through a three-tier system (primary, secondary and tertiary) of care (The Bhore committee’s visualisation of India’s health system was influenced by the National Health Service in the UK. In the short-term plan of the committee, one primary health centre was visualised for every 40 000 population. Each primary health centres in the short-term programme was to have 2 doctors, 4 Public Health Nurses, 4 Midwives, 4 trained Dais (local women who served as midwives) and other support staff. In the long-term plan—called as the three million plan, the District Health Organisation was to have a hospital with a bed: strength of 2500 at the district headquarters, 3–5 secondary centres each with 650 beds and 15–25 primary health units with a bed strength population of 10–20 thousand.). It justifies the large expenses of building such a system as being a ‘good investment’ for the country’s progress ( table 1 quote 1.3). Primary health centres were part of this original blueprint intended to be first access health facilities, within a three-tier system. A conscious decision was taken to put allopathic doctors in charge of these centres; and tilt their roles towards being ‘social physicians’. However, recognising fiscal and human resource constraints in building such a system, the report also proposed a ‘short-term’ diluted model, intended for the initial years of independence ( table 1 , quote 1.4).

Independence (1947) to 1970s

The Bhore committee had advocated a radical shift from the sporadic disease-campaign approach that existed pre-independence. Such a shift required funding support, but post independence, India’s political focus was on economic growth through industrialisation 33 - and the health sector lost priority in budget allocations (online supplementary table 2 ). Health was declared as a “state” subject (states were tasked with developing/maintaining the public health infrastructure), with the federal government offering policy directions and funding priority programme (Plan 1). 12

Microcontext of primary healthcentresinIndia (source: data from interviews and focus group discussions)

In the first decade after independence, building urban hospital infrastructure was given preference 34 —and the first primary health centre was set up only in 1952. 35 Influenced by the ideologies of the Rockefeller Foundation (that advocated technocentric, antimalaria strategies) and the Ford Foundation (that funded family planning), vertical interventions for these two issues—along with some attention to tuberculosis, leprosy and smallpox-gained priority (plan 1–4). 12 36 This change in proposed tactics from Bhore’s approach has been explained in Indian policy documents as necessary due to budget and human resource constraints. An urgent need to correct the budgetary neglect of family planning has also been argued for ( table 1 , quotes 2.1, 2.2, 2.3). By the fourth plan, the budget outlay for family planning had increased dramatically; in plan 1, of the total plan investment, health expenditure was 3.33% and family welfare was 0.01%; in plan 4, health expenditure was 2.13% and family welfare was 1.76% ( online supplementary table 3 ). A review in 1961 showed that primary health centres fell short of Bhore’s recommendations in terms of numbers/coverage and were severely understaffed. 37 In addition, staff of the family planning programme had begun to dominate these centres. 34

Late 1970s to 1980s

In India, the Alma-Ata declaration brought into policy focus the original ideals of the Bhore committee—in a globally ratified package. In this period, the works of eminent sociologists and policy documents in India—endorse the PHC approach—reiterating disadvantages of ‘ western’ curative models, the need to overcome cultural gaps between the people and the system, and provision of care close to people 38–41 ( table 1 , 3.1 and 3.2). The resurgence of malaria in India, in this period, has been argued as the inability of a poorly-funded health system to ‘maintain’ programme results (plan 4). 12 In addition, coercive sterilisation strategies by the Indian government had tarnished the reputation of the family planning programme; thus, ideologies that emphasised community participation (in lieu of force) were politically championed (plan 6) 12 42 ( table 1 , quote 3.3). All this led to increased funding for primary health centres and their rapid expansion (plan 5,6). 12

Soon after Alma-Ata, its vision was revisited in international forums; and a selective package of interventions was advocated instead. 43 For India, the selective ethos that had already been rooted in the system was easy to maintain. Thus, while numbers of primary health centres rapidly increased (see figure 2 ), these still offered limited services. National surveys (1986–1987) indicate that people sought outpatient care mainly at private doctors (53%) or the public hospital (17%); only 4.9% used primary health centres. 44

Expansion of primary health centres in India.

Late 1980s to 2005

A move towards neoliberal ideologies (free market, attenuation of the government role, fiscal austerity) began in India in the late 1980s, though structural adjustment policies in the country were officially launched only in the early 1990s. 45 These policies advocated cost-containment strategies in the public health sector and a push to move non-priority services to the private sector. 46 47 Written policies within India rationalise these reforms by arguing that during a time of fiscal constraints, equity can only be achieved by targeting demographics, geographies and type of services ( table 1 , quotes 4.1, 4.2). Other new global health assistance players also arose during this period; and international attention shifted to reproductive and child health, HIV/AIDs, tuberculosis and vector-borne diseases in line with the Millennium Development goals. 48 49 The revised health policy 2002 reflects these developments—but is silent on the notions of ‘comprehensive PHC’ that the previous policy had defended eloquently 50 ( table 1 , quote 4.3). The expansion of primary health centres stopped gradually ( figure 2 ). The basket of services at primary health centres remained restricted—though the disease portfolio (and extent of technology/ drugs available to vertical programme) changed.

From 2005 to present

In 2007, an initiative of India’s central government, the National Rural Health Mission—whose ideologies supported horizontal strengthening of services, community involvement and bottom–up planning ( table 1 , quote 5.1)—increased overall financing to the health sector—focussing mainly on states with poor health indices. 51 The mission carried out substantial infrastructural upgradation and contractual staff recruitment at primary health centres. 52 The global Universal Health Coverage discourse caught on in India around 2010; and brought attention to the need to reduce out of pocket expenditure and provide financial protection to people. 53 Current political discourse, reflected in the revised policy of 2017, prioritises (1) the need for financial protection for hospitalised care (justified in terms of increasing out-of-pocket expenditures) and (2) the inclusion of non-communicable disease interventions at the periphery (justified in terms of changing epidemiological burden) ( table 1 , quote 5.2). 54 55 In the revised policy, ‘comprehensive PHC’ mainly refers to the expansion of primary-level service packages to include non-communicable diseases. 54

In summary, the public health system in India has been subjected historically to gross underfunding, and public health expenditure in India is one of the lowest in the world (at US$39 per capita, compare China: US$203, Sri Lanka: US$66, Bangladesh: US$14, Brazil: US$483; year 2011). 56 The development of the public health system and strengthening of its infrastructure has happened in small spurts. But piecemeal vertical solutions have mostly been the preferred operational choice; defended by policy discourse in terms of epidemiological situations, budget and human resource constraints and prioritisation. This kind of macro context has led to primary health centres that offer only selective services, focus heavily on programme of national (and international) priority at any given point in time and work in an overall poorly funded health system.

Micro context

To situate the experience of the primary health centres, box 1 provides a brief outline of the state context.

Summarising from box 1 , the state context highlights the existence of a good network of primary health centres, with policies to combat human resource vacancies at these centres, indicating a history of political commitment to this cause. Post 1990s, however, overall state expenditure on health has reduced (in comparison to other Indian states that had made similar social progress). Further, national (and international) emphasis on priority interventions- has resulted in only ‘essential’, public health services being available at primary health centres in the state, mostly delivered through vertical programmes. Such a state-context ensconces the micro level issues below:

Most doctors do not find value in their roles at primary health centres

All doctors we interviewed view primary health centres mainly as platforms for national programmes and schemes; since much of their time as well as the targets given to them by higher authorities focused around these activities. They perceive work at these centres to be focused on ‘preventive care’ activities that involved acquiring administrative rather than clinical skills. This kind of work is clearly not of value to doctors. For most doctors, the only clinical work available at these centres is running the Out Patient Department clinics (OPDs). But, at an organisational level, there are no targets or incentives for delivering OPD services. In addition, most doctors do not view primary care OPDs as ‘good clinical work’; where their professional expertise could be used fully (see box 2 ). Further, most doctors feel that good clinical work at primary health centres is hampered by the lack of drugs and supporting facilities such as functional operation theatres, diagnostics and equipment.

Micro context: illustrative quotes

‘Even for a general medicine graduate the primary health center is not a great place… in his course, he learns about many good-good medicines…and here he will be confined to using 4–5 of them here…and can’t use his knowledge….so why will he come? Coming here is not an issue…but without drugs and equipment, no one will work. (Medical Officer, 23 years, Female, Fresh graduate)

‘It is very horrible work at the primary health centre. At the rural hospital (second tier of the system), work is more clinical. If you are a clinician by heart, then you should go to there and not here. Primary health center work is only meant for people who are administratively strong- management is their strength” (Medical Officer, Male, 45 years, experience-8 years, has also worked in other tiers of the system for 5 years).

The services offered at primary health centres were few and often did not meet communities’ expectations

P1: … it is like diseases are all of different types. Then they (at the center) give two medicines to all type of illness. All are similar they don’t change, this is what he wants to say.

Moderator: Doesn’t it happen in private?

P4: In private, tablets are powerful. Whatever the disease is medicine for that disease only it is given, here it is not like that.

P5: Quick difference is not felt in government.

P1: The power of government medicines is less. They are all simple. The medicines are very normal. What they say in government, same type of medicine is given no matter which disease you go for…. the tablets are same only and we don’t get any difference that fast. (Community discussion, mixed gender group, location: far from district head-quarters (>40 km), the primary health center was about 1 kilometre away from place of discussion, and less than 10 years old)

Strained community-staff interactions further deter utilisation of services

P1: nobody takes care there (at the primary health center)

Moderator: What kind of care?

P2: Taking care of us means, give medicine and injections and tablets to patients, give good service, check-up…

P1: Whatever is paining you have to treat, accordingly. Give saline if we ask.

P6: …giving service on time…

P2: Here in the primary health center, if ever we go, they don’t even look at us, never take BP, nothing ever, this is their method….

P7: And if you go there, get the (case) paper issued…then wait in line…even then they don’t treat properly, don’t touch us, they just give the medicine and ask us to go. (Community discussion, Mixed gender group, Location: Far from district head-quarters (>60 km), primary health center in the same village as place of discussion, center more than 10 years old).

“Once there was a drunk man…came in demanding I give him IV at once since his hands and legs are paining. Was shouting here -standing right where you are…Gets angry because I gave the IV line to the other patients. I have only limited IV lines- and others are also patients…how can we attend to everyone in a fast way” (Nurse, 25 years, Female, experience-5 years)

Out-patient care gets low preference-within target-oriented structures

The primary health centers’ biggest role is in national program…because of the national program and their targets, there is less focus on the OPD…there are a lot of targets…conduct deliveries…do vaccination…then all new programs have their own targets. (Medical Officer, Male, 39 years, experience-12 years).

Risk-averse behaviours and poor referral practices deter its function as a ‘link’ to higher tiers.

Our senior used to tell us ‘if you want to take a risk, then you do it elsewhere ….if you want to play, then do it only if you have the guts…if you want to play, do it elsewhere or in your private practice….not in the primary health centre…nothing happens here and don’t try to change things… Also, the issue is that if there is some issue…even a tiny issue, at least five journalists will turn up here…and we have to answer them…and they will dramatise the episode.’ (Medical Officer, Male, 33 years, experience-9 years).

In short, most doctors are not happy at primary health centres; and said that they would prefer private sector jobs, that were regarded as more lucrative, or express a preference for working at higher tiers of the public health system—where the clinical work is perceived as more challenging. In the region, we collected empirical data from, many posts for second doctors at primary health centres are vacant—in a desperate attempt to fill these posts the government has enforced a compulsory 1-year stint at primary health centres for new medical graduates. The graduates we interviewed do not plan to stay on beyond completion of this stint.

The services offered at primary health centres often do not meet communities’ expectations in contrast to services offered by local private practitioners

The community views and evaluates primary health centres like any other curative health facility on the basis of OPD services (and some inpatient services). Community expectations are clearly centred around these centres being good, primary-level curative care facilities—dispensing a variety of free drugs and treatments—and most centres could not live up to these expectations. First, primary health centres, designed under the ethos of ‘selective care’, offer a very narrow range of curative health services—and have only a few generic drugs available. The community feels that these centres dispensed the ‘same medicines for all diseases’; and even those medicines were not given at times due to stock-outs (see box 2 ). Second, these centres function mostly from a ‘rational clinical care’ perspective; and do not cater to demands for ‘ instant relief’ by the community. Hence, the treatment offered by primary health centres is often in contrast to those offered by local private practitioners. These practitioners, not bound by the strict regulations that government doctors had to adhere to, cater to ‘mass appeal’—by administering strong drug combinations that provide instant relief, and intravenous rehydration therapies as per the patients’ demand (even when these treatments were clinically irrational). These practices set a different set of expectations in the community about primary-level care—which primary health centres could not address. In addition, strained community–provider relationships (described in the next section) adversely affect people’s opinions of these centres. All these factors together make the local private practitioner the first access point to primary-level curative care. Primary health centres today, are, at best, accessed for select services such as immunisation, family planning, for antidotes to animal bites and treatment of certain diseases like tuberculosis and malaria.

Strained community–staff interactions further deter utilisation

A common community complaint is the lack of ‘attention’ given to them at primary health centres. Attention appears to comprise (1) the doctor taking time to understand the issues, (2) doctor using the stethoscope and touching the patient during the interaction, (3) support staff who speak politely and follow doctors’ instructions and (4) the prescription of strong medicines. All this, the community feels, does not happen in most primary health centres (see box 2 ).

Doctors’ notions of attention are different from those of communities. For one, most doctors do not believe that the type of ailments people came with to primary health centres require more than a quick appraisal. This quick appraisal and the small window of contact with the doctor sometimes has adverse consequences. For instance, one patient we met—who reported throat pain—had not informed the doctor at the centre of her prior visits to a specialist who suspected throat cancer. When asked why she did not share this information, her answer was that the doctor never asked. She also suspected the doctor of pocketing throat-related medication from the centre. This case is also an example of suspicious attitudes of the community towards primary health centre staff. Indeed, the community, in general, has poor views about all public institutions as well as employees who work at these institutions (It must be noted that though people relied on local private practitioners for first access, the community had developed a sense of wariness about these practitioners; people believed that private practitioners were sometimes money-minded, had tie-ups with drug stores and prescribed unnecessary and costly medicines).

The wariness of the community towards the staff is not a one-sided phenomenon. Primary health centre doctors express frustration over patients who demanded drugs like cough syrups and intravenous rehydration—despite having no clinical need. Nurses and laboratory technicians report of people fighting with them over the non-arrival of laboratory reports or unwillingness to wait in the line for their turn (see box 2 ). In summary, mutual wariness between the community and staff at primary health centres deters a trust relationship, essential to the provision of good primary-level care.

Outpatient care gets low preference-within target-oriented structures

The biggest contribution of primary health centres within the health system is perceived—by almost all health system staff—to be in operationalising vertical programme and schemes (see box 2 ). This perception stems from a complex interaction of factors—including strict targets set within the system for vertical programme; and targets which the staff feel compelled to complete because they are held accountable only for these within bureaucratic work environments. Staff express more concerns on how they ‘report’ the schemes—rather than how they carry out activities under various schemes. Also, activities whose targets (numbers) are checked less frequently by higher level managers get less attention. Within such target-oriented vertical structures, there is little support and encouragement for activities—like the OPD—from the authorities. While two OPDs are mandated in a day, it is an accepted practice to conduct only one. In short, basic curative care at primary health centres has been side lined; this fact, exacerbated by the lack of drugs and equipment, in an environment of mutual wariness between the community and health staff, has made poor quality OPDs a harsh reality at these centres.

Risk-averse behaviours and poor referral practices at primary health centres deter its function as a ‘link’ to higher tiers

Doctors perceive themselves as ‘professionally isolated’ at primary health centres and in practice-feel delinked from the referral tiers. They express concerns about having to deal with consequences of adverse events (such as a death or a mishap) with no peer support. This isolation, combined with drug-stock outs and lack of equipment/diagnostics, has led to ‘risk-averse’ behaviour among doctors, resulting in an increased number of referrals from primary health centres than necessary from a clinical angle (see box 2 ).

Health staff at primary health centres do not see the referral tiers as ‘support’ to their work: when cases were referred, they see this as passing on the legitimate clinical work of the higher tiers. This ‘referral’ is not perceived as making any difference to the goals of the centres—whose work is viewed as that of programme operation. Hence, staff do not think of it as their duty to follow up on referred cases (The exception to this was delivery. In Maharashtra, recent efforts have been made to strengthen ambulance linkages between the primary health centres and the higher tiers- to ensure that referral during delivery was timely. The primary health centre was held accountable for such referrals).

Consequently, instead of becoming an integral link in a referral system, primary health centres have become institutes for ‘preventive’ issues and ‘programmes’ that refer even primary-level cases. Hence, these are thought of as ‘too basic’ and places that ‘can’t really do much’. Disparaging attitudes towards primary health centres are encountered in conversations with almost all health staff, but most explicit among doctors and administrators.

A summary of the micro context is presented in table 2 .

What has happened to primary health centres in India illustrates some of the challenges to the implementation of the PHC approach. Figure 3 summarises the experience reported here. Below, we explain the situation of primary health centres using both top–down and bottom–up perspectives of policy change.

Summary—what happened to primary health centres in India.

From a top–down perspective, the situation of primary health centres in India can be considered as a consequence of changing national ideologies and fiscal priorities. The ideological climate that favoured the development of primary health centres existed only in small spurts; and these centres lost out on funding when competing ideologies (such as that of neoliberalism or vertically funded aid) gained prominence. Thus, many states in India have primary health centres with severe infrastructural constraints. In the state of Maharashtra, however, early commitment to expansion of primary health centres through decentralised mechanisms and availability of human resources and supporting policies to combat vacancies have led to primary health centres with better infrastructure than Indian averages. Despite this, a decrease in public funding for health since the 1990s; combined with an increased focus on delivery of ‘essential’ public health services—has had consequences for primary health centres in the state. In particular, the operational policy choice of ‘selective’ services at state (and national levels) manifests in the form of few services being available at primary health centres, mostly pertaining to vertically run programmes. These services are based on health system priorities rather than the felt needs of people.

From a bottom–up perspective, the issues become more complex. The manifestation of the above macro issues (the provision of select services in primary health centres, in an underfunded context) interact with local actors’ norms and behaviours. Doctors, whose ambitions tend towards specialisation find little professional fulfilment in providing primary-level care services-even more so, in situations where the services they can offer are extremely restricted. The institutional context of primary health centres—having no targets for outpatient care, vertical reporting structures, and the tacit promotion of risk-averse behaviours—further lowers the attention given to outpatient care. Patients find few services offered by primary health centres relevant to their needs (a manifestation of the ‘selective care’ macro context); but this situation is worsened by healing norms in the community that favour instant relief (norms that private practitioners cater to, but primary health centres cannot)—and a deep-seated suspicion of public sector employees. All this has led to primary health centres today that are a far cry from PHC principles of first access and comprehensive care provision.

We have used the example of primary health centres to illustrate some of the complexities in implementing PHC. Many issues encountered in the macro context—competing neoliberalist ideologies, the pervasiveness of vertical funding, low budgets for PHC, and more recently, PHC being subsumed inside the UHC debates—have been discussed in global literature. 4–7 These macro issues have been shown to manifest at micro-levels of the system - for instance, Baum et al poignantly illustrate how neoliberal ideologies manifest at primary health centres in Australia, reducing the envisaged community engaged, comprehensive service model to mere outreach centres. 57 There is less literature on how the ‘day-to-day’ realities of the health system (the organisational culture, actors’ values and actions) affect PHC implementation. In our case study, these realities include an organisational context that tacitly promotes risk-averseness; the neglect of outpatient care in favour of targeted activities; doctor’s mismatched professional aspirations; and mismatched expectations of care between the community and staff. These issues-in addition to the macro context can be thought of as important influencers of policy success. 8–10 26

In India, structural deficiencies and staff vacancies at primary health centres are so striking in some areas 13–15 that it is a challenge to look beyond these issues. In a state like Maharashtra, these issues are not apparent and primary health centres have been called ‘well-functioning’. But the term ‘well-functioning’ masks the fact that even the country’s ‘good’ primary health centres still cater to only a small portion of people’s needs, are not first access points, get bypassed and fail to become the ‘heart of a people-centred integrated system of care’. 58 Even in the state of Tamil Nadu, which is well known for good quality drugs in the public system—and ‘good health at low cost’ 59 —the utilisation of outpatient primary-level services in the rural public sector is about 10%. 60 Thus, what remains today of primary health centres, even at their best, is an empty shell, stripped of the original PHC philosophy. Andrew et al argue that such interventions embody the ‘technique of successful failure’ 61 for the mimicked form of primary health centres, though an empty shell, can look like a successful PHC intervention.

In India, people spend large amounts on outpatient care for ‘day-to-day’ ailments—as much as hospitalisation costs. 62 These out-of-pocket costs can be minimised by the use of primary health centres. In addition, primary health centres are one of the few places where the rural community can access a qualified doctor—for presently, it is unqualified practitioners who provide most primary-level care. 63 64 Hence, it is imperative that primary health centres embody core PHC principles- and become first access institutions that provide comprehensive care, respond to community needs, and guide towards specialty care. In box 3 , we have tried to summarise some directions for primary health centres in India. Since the situation in India mirrors the condition of peripheral health centres in many LMICs, 65–68 elements of box 3 may be relevant across countries.

Directions for Indian primary health centres

Ideological: Refocus on PHC principles of universal access, provision of comprehensive care close to the community, taking into consideration community needs.

Policy directions: Increased funding to primary health centres, expansion of the current ‘service model’ of primary health centres, improvement of institutional practices and building of community trust.

Focus on horizontal strengthening of health systems through improving infrastructure, human resources and drugs—in conformation to national quality standards.

Expand the ‘service model’ of primary health centres to provide comprehensive care—through widening the basket of services provided at primary health centres.

Rethink about the roles of doctors at primary health centres to ensure better utilisation of their professional expertise.

Expand the roles for nurses and other practitioners at primary health centres (and consider advanced trained nurse practitioners and non-physician clinicians as main providers at these centres).

Balance the attention given to indicators of vertical programmes and outpatient care at primary health centres in district and state-level reporting systems.

Provide routine mentorship and backing/support for staff at primary health centres to counter professional isolation and risk-aversion tendencies.

Promote bottom–up consideration of issues at primary health centres (taking into account community needs); and develop institutional mechanisms for arriving at participatory solutions.

Community and health system level messaging to deal with disparaging attitudes towards primary health centres and primary-level care in the public system.

In summary, this paper, using the example of primary health centres, illustrates some of the contextual complexities of PHC implementation—which can be at macro levels (pertaining to ideologies and fiscal priorities) and at micro levels (pertaining to the norms and everyday realities of front-line actors) of the health system. It cautions against masked successes—that even while appearing to work well, in reality, maybe disengaged from the philosophical orientation of PHC.

This paper has some limitations. In the macro context, the complexities of interactions between global and national ideologies have been addressed only briefly. In addition, our micro level evidence is drawn from one state, and infrastructural conditions in other states are different. Also, we did not look into issues of local ownership or intersectoral coordination at primary health centres even though these issues also embody the PHC approach. In our case, people did not emphasise geographical distances as barriers to access—this could be because of the better developed transport in the study area. Also, we could not elicit caste barriers to access in our case study; which have been shown as important in other studies. 38 62 Given these points, our evidence is only illustrative of the complexities of implementation.

Acknowledgments

This paper has been funded through the Health Policy Analysis Fellowship programme, supported by the Alliance for Health Policy and Systems Research, Switzerland. We acknowledge the mentor team of the fellowship programme—Dr. Irene Agyepong, Dr. Jeremy Shiffman and Dr. Maylene Shung-king; and all the fellows of the programme—for their very useful comments and inputs on the paper—during two workshops held in December 2017 and October 2018. We thank the Center for Social Medicine, Pravara Institute of Medical Sciences, in Ahmad Nagar, Maharashtra, for data collection and logistical support, in particular, the interns who worked with us and faculty, Dr. Somasundaram and Dr. Thitame. We thank the community and the health staff who shared their valuable thoughts with us during the study. We particularly thank Dr. Sundararaman, Tata Institute of Social Sciences, Mumbai, for his comments on the study idea, early findings from the study and reflections on this paper. We specially thank Dr.Jaswal, Deputy Director, Tata Institute of Social Sciences, Mumbai, for her numerous inputs into study design and protocol development; and comments on initial analysis of study results.

• World Health Organization
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Handling editor Seye Abimbola

Contributors SR developed the initial design for the study, with mentorship from LG and SM. Data collection was done by SR, and both LG and SM commented on initial data summaries and the analysis. The first draft of the paper was written by SR, and reviewed by SM and LG. The final draft has been reviewed by all three authors. SR is the guarantor of the paper.

Funding This study is funded through the Health Policy Analysis Fellowship programme, supported by the Alliance for Health Policy and Systems Research, Switzerland, and managed through the University of Cape Town, South Africa. The Alliance for Health Policy and Systems Research funded the Health Policy Analysis Fellowship programme to build the capacity of doctoral level students to undertake research in this field. The first author of this paper was awarded this fellowship.

Competing interests None declared.

Patient consent for publication Not required.

Ethics approval Ethical approval for the study was taken from the Institutional Review Board at the Tata Institute of Social Sciences, Mumbai, India, in April 2018.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

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Article Contents

Introduction, authors’ contributions, supplementary material, conflict of interest statement, acknowledgements.

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The development of urban community health centres for strengthening primary care in China: a systematic literature review

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Harry H. X. Wang, Jia Ji Wang, Samuel Y. S. Wong, Martin C. S. Wong, Stewart W. Mercer, Sian M. Griffiths, The development of urban community health centres for strengthening primary care in China: a systematic literature review, British Medical Bulletin , Volume 116, Issue 1, December 2015, Pages 139–154, https://doi.org/10.1093/bmb/ldv043

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This review outlines the development of China's primary care system, with implications for improving equitable health care.

Government documents, official statistics, and recent literature identified through systematic searches performed on NCBI PubMed.

Community health centres (CHCs) are being developed as the major primary care provider in urban China, with laudable achievements. The road towards a strong primary care-led system is promising but challenging.

The effectiveness in improving equitable care through the expansion of primary care workforce and redesign of the social medical insurance system warrants further exploration.

Healthcare disparities exist in the health system wherein universal health coverage and gatekeepers have not yet been established.

Future prospective studies should aim to provide solutions for strengthening the leading role of CHCs in providing equitable care in response to population ageing and multimorbidity challenges.

China, as the largest and most populous developing country in economic and demographic transition, has been shaping its primary care system during the past several decades. 1 , 2 In the early 1950s right after Mao's Revolution, health stations with barefoot doctors carried out population-based preventive health services and mass mobilization health campaigns. They acted as the initial point of contact in relation to the secondary care. The government owned most enterprises in urban areas, and employees and their families were provided with free access to basic medical care. Meanwhile, the cooperative medical scheme was operating in rural villages, covering over 90% of the population. The massive subsidy granted by the government ensured a nation-wide healthcare coverage in both urban and rural areas during the planned economy period. Starting from the early 1980s, however, the healthcare system became market-oriented in tune with the radical economic reforms and urbanization. The government shrank its investment in primary care, and health care was seen as free-market consumption activities instead of public good. 3 Under-trained doctors constituted the majority of general practitioners (GPs). The generalists were deemed less competent than specialists at secondary care, where high-cost, treatment-orientated care was dominant. Health care relied heavily on user fees and drug revenues to maximize revenue. This has led to an increasing proportion of individual out-of-pocket payments and inadequate healthcare coverage for almost 20 years. 4

In view of the dilapidated primary care infrastructure and healthcare inequity, promoting community health service (CHS) has become a prioritized policy agenda, in line with the Chinese government's overall goal of re-strengthening primary care networks based on community health centres (CHCs) (Fig. 1 ). As part of the comprehensive healthcare reform embarked on in 2009, the social and medical insurance schemes have been improved, including (i) basic medical insurance for urban employees (mandatory for employed individuals) and residents (voluntary at households, including children, students, elderly, disabled and other non-working urban residents); (ii) new rural cooperative medical scheme (NRCMS) for rural citizens (voluntary) and (iii) medicaid system for deprived populations. 1 , 5 The ‘Healthy China 2020 Plan’ depicted an equitable healthcare system delivering safe, effective, convenient and affordable basic health care for all citizens by 2020. 6

Healthcare system and primary care providers in China. The healthcare structure is depicted according to the most recent National Healthcare Policy-announcement of strategic plan on National Health Care Service System (2015-20): State Council, P.R. China, 2015. The dashed lines denote dual referral channels between primary care and secondary (tertiary) care providers. Other hospitals refer to hospitals established by the military, state-owned or collectively owned enterprises. Other primary-level healthcare facilities include township health centres and stations, village clinics and countryside infirmaries. Professional public health institutions include centres for disease control and prevention, regulatory and supervisory bodies, maternal and child health centres, first aid centres and stations, as well as blood donor centres. Other public health institutions refer to institutions established by the state-owned or collectively owned enterprises.

However, unlike primary care in the UK, primary care is currently still weak in China. Primary care providers do not have a gatekeeper function, and health care is not free at the point of access. Both GPs at CHCs (primary care) and specialists at hospitals (secondary care) can be directly accessed by walk-in patients. The social medical insurance, albeit being developed, offers limited benefits. Patients' private out-of-pocket payment contributed 42% of total health expenditure in 2008 5 as most patients are currently served through a fee-for-service delivery system. However, China, like other developed countries, is also facing numerous challenges such as an ageing population and growing burden of chronic disease risk factors particularly in urban areas. 7 In this review, we have sought to outline China's primary care in urban areas where CHCs serve as the major primary care provider. The review had a major focus on the development of CHCs under the national healthcare policies and also the impact of primary care reform on key issues including service provision, patients' experiences, service utilization, emerging primary care organizational models, disease management and improvement of maternal and childcare based on the most recent findings.

Search strategy

The search strategy was developed to identify literature on national policies on developing community health care, and empirical findings relating to service provision, patients' experiences, service utilization, primary care organizational models and healthcare management. Given the nature of this review, we did not aim to perform a meta-analysis pooling results. A systematic search was performed in September 2015, by a review panel consisting of one public health professional (H.H.X.W.) and three primary care professionals (J.J.W., M.C.S.W. and S.Y.S.W.) to identify literature in both English and Chinese ( Supplementary Fig. S1 ). In the first stage, a combination of terms and synonyms pertaining to primary care, family medicine, general practice and community health centres were developed as text words to search potentially relevant literature published in NCBI PubMed-indexed journals in the previous 36 months. In the second stage, full-text articles that covered policy development, CHC structures, service utilization, organizational models, patients' experiences, disease management, as well as maternal and child care were included following the inclusion criteria set after a panel discussion. A total of 79 articles were identified according to the title and abstract by two investigators (H.H.X.W. and M.C.S.W.) independently. In the third stage, all panel members conducted a selective review based on the full text of publications retrieved in the previous stage. The exclusion criteria were articles that conveyed no empirical evidence or quantitative studies with small sample size (<800). If similar findings were presented from more than one publication, only the more recent and informative full-text article was included. Reference lists of selected articles were also examined. Given that a significant body of work regarding the progress of the primary care reform has taken the form of official publications, the China Health Statistics Yearbook series (from 2002 to 2015) and government documents (from 1997 to 2015) were also reviewed by native Chinese speakers (H.H.X.W. and J.J.W.). Disagreements were resolved by consensus after discussion or, when necessary, by appeal to the senior investigators (S.W.M. and S.M.G.). A total of 38 publications including 20 government official publications and 18 articles from NCBI PubMed were reviewed. Five studies gathered data from nation-wide samples, while the other 13 studies were conducted regionally with widespread geographical distribution across China ( Supplementary Table S1 ).

Policy development

part of the urban community construction. It is delivered predominantly by GPs as the cadre, based at primary-level health care facilities, with an appropriate use of community resources and health care techniques. The services should be centred on person within the family context, focusing on the basic health care need of women, children, elderly, disabled and patients with chronic conditions. It should integrate prevention, treatment, protection, rehabilitation, education, and family planning, as a six-in-one care package, to maintain and improve population health. The CHS is fundamental to the ultimate goal of achieving primary care for all. 10

Twenty official guidelines and document milestones in China's primary care reform

The long-existing Ministry of Health (MoH) and the National Population and Family Planning Commission (NPFPC) have been merged into, and reconstituted as, the National Health and Family Planning Commission (NHFPC) of the P.R. China in March 2013. The NHFPC is expected to strengthen the supervision of healthcare institutions and professionals to regulate service provisions and deepen the current healthcare and primary care reform to address grass roots health issues. The reference numbers are consistent with that in the manuscript text.

Several policy regulations were further issued in 2006, 14–19 covering the premises, registration, operation and pricing at the CHCs. Equity, efficiency and accessibility were highlighted. These plans laid CHCs in place in every neighbourhood within a 15-min walking distance to ensure close-to-home primary care. The government sector with public investment were required to play a leading role in developing primary care, while investments from the social and private sector were also encouraged. 14 The academic discipline of GP began to emerge in medical universities with the aim to build a cohesive undergraduate medical curriculum, a standardized post-graduate professional training, and continuing education for GPs. The GP training scheme was structured and included class-based learning, clinical rotation and community practice in primary care medicine. 17 , 19

A series of detailed action plans were subsequently announced between 2009 and 2011, 20–24 including the effort for improving the provision of public health care through a nation-wide implementation of basic public health (BPH) service package. 23 The government subsidies on the BPH service package were determined by the number of people served by the CHCs, with the minimum amount increasing from ¥15 (£1.5) to ¥25 (£2.4) in 2011. The BPH services contained eleven programmes covering (i) establishment of health profiles and medical records; (ii) provision of health education; (iii) disease prevention and vaccination; (iv) health management for the elderly (aged 65 years and above), pregnant women, children (aged 0–6 years) and patients with hypertension, diabetes or serious mental illness; (v) surveillance and control of infectious diseases and public health emergencies and (vi) sanitation control and monitoring. 23 Since 2010, the adoption of a national essential drug list (EDL) with government-imposed price control has been mandatory at all primary care facilities. 25–27 The implementation of EDL aimed to ensure the procurement, pricing, financing and quality of medicines to improve drug efficacy, safety and cost-effectiveness.

The most recent policy stated by the central government in 2015 has re-depicted the structure of the overall healthcare system to enhance the healthcare accessibility and equity, through a step-wise manner with dual referral channels between primary care and secondary (tertiary) care (Fig. 1 ). 27 Multiple organizational models of CHCs were encouraged. The construction of a nation-wide ‘cloud’ big data system has been in progress. It is expected to be completed by 2020 to support chronic disease management at primary care with a dynamic picture of the nation-wide population health profiles. 27

Service provision and human resources

Primary care facilities in urban areas are organized around CHCs. The national statistics have revealed the expansion of CHCs and subordinate health stations policies in the past decade. Compared with a 1.38-fold increase in hospital constructions between 2002 and 2013, there was a dramatic increase by 3.30-fold in the number of CHCs from 2002 to 2007 (8211 versus 27 069), followed by a mild increase from 2010 to 2013 by which the number of CHCs exceeded that of hospitals (33 965 versus 24 709) (Fig. 2 A). However, the national statistics on the healthcare utilisation did not prove that CHCs care has been commensurately improved in response to the increasing healthcare need of the population. The total million person-time of diagnosis and treatment at the upper level remained far exceeding than that at CHC level (1243 versus 75 million in 2002; 2742 versus 657 million in 2013), albeit the CHCs showed a remarkable pace of increase (8.73-fold [657/75] versus 2.21-fold [2742 /1243]) (Fig. 2 B).

Number of healthcare facilities with total person-time of diagnosis and treatment between 2002 and 2013 in China. All statistics were retrieved and calculated (when necessary) from the China Health Statistics Yearbook (renamed as China Health and Family Planning Statistics Yearbook, since 2013), which are official healthcare report series complied by the National Health Family Planning Commission (NHFPC), P.R. China. Historical statistics on the number of total community health centres and stations are only available from 2002.

The service provision at CHCs adheres to national guidelines, and all primary care providers are regulated by the local health bureau to ensure the quality of services. 10 , 13 , 15 , 16 , 23 This includes the standard provision of both western and traditional Chinese medicine services that are available in most CHCs. In general, all CHC health care staff are paid a fixed salary plus a CHC annual income-related floating salary. Patients can walk in directly to see a doctor at CHCs after paying a fixed one-off registration fee upon the visit. Healthcare personnel at CHCs include clinical physicians, public health doctors, registered nurses, pharmacists, laboratory technologists, managerial and assistant staff. Telephone access as well as evening and weekend clinics are commonly available. A novel concept of GP team-based service provision enrolling community residents with the GP teams has been recently promoted since 2011. 28 This approach requires CHCs to form GP-led team consisting of GPs, nurses and sometimes public health doctors to provide continuous and comprehensive services to residents enrolled, normally with a maximum of 2500 registrations per team. It was reported that patients who contracted with GP team service had greater satisfaction. 29 Another recent longitudinal study found that capitation payments and the provision of services tailored to the local health priorities served as key factors associated with beneficial long-term relationships between patients and CHCs. 28 It suggests that the reforms of incentive structures should be reinforced to explore effective and viable payment methods for improving primary care performance.

The enhanced service provision also resulted from the rising number of medical practitioners working at CHCs (173 838 in 2013 versus 19 451 in 2002). Since 2002, the number of daily clinical consultations per doctor at CHCs has increased by 25.6% (15.7 versus 12.5 in 2013). More than one-third (37.1%) of CHC medical practitioners had a bachelor's degree or above, in contrast with the education level of CHC medical practitioners in 2002 when it was slightly over 1 in 10 (13.0%) who had completed undergraduate education (Table 2 ).

Ten-year development of primary care between 2002 and 2013 in China

All statistics were retrieved and calculated (when necessary) from the China Health Statistics Yearbook (renamed as China Health and Family Planning Statistics Yearbook, since 2013), which are official healthcare report series compiled by the National Health and Family Planning Commission (NHFPC), P.R. China. Historical statistics on the number of total community health centres and stations are only available from 2002.

CHCs, community health centres (including the subordinate community health stations).

Patients' experiences

The Chinese version of Primary Care Assessment Tool-Adult Edition (PCAT-AE) has been used to evaluate the process of primary care delivery measured by patients' experiences. 30–32 The concept of patients' experiences was contextualized on the basis of the five core attributes of primary care, i.e. first contact, continuity, coordination, comprehensiveness and community centredness from an international perspective. 33 The PCAT focuses on patients' experience of, rather than satisfaction with, healthcare delivery, which could minimize subjective bias that is due to socio-demographic variations and patient expectation. 34 , 35 The PCAT items in each core domain are scored according to a 4-point Likert-type scale, with higher scores indicating better primary care experiences. 31

Generalists at CHCs were more likely to provide better primary care, compared with specialists at outpatient department in hospitals. 30 In one large study conducted in seven geographical regions, approximate one-third (33.4%) of patients reported an optimum PCAT score (higher than the third quantile of the score range) on the overall primary care experience. The proportion of subjects with optimum scores in individual primary care domains ranged from 62.1% in the comprehensiveness of service attribute to only 16.6% in the community orientation attribute. 31 This may be a reflection of the current clinical practice where major attention is paid to disease treatment per se and less to patients' personal beliefs, health attitudes and lifestyle changes. Accordingly, the outreach work such as door-to-door visits, early screening and disease prevention are considered less cost-effective, compared with on-site physician treatment and drug prescriptions.

It was also found that patients with social medical insurance were more likely to have optimum scores in most of the primary care attributes and reported overall better primary care experience. 31 The rapid escalation of healthcare costs in recent decades and the incomplete coverage of health insurance may partly contribute to the healthcare inequality. Uninsured patients, most of which belong to internal migrants, 36 probably have poorer access to or can less afford comprehensive care and appropriate investigations within primary care and between levels of care, resulting from being less able to pay. The primary care experience was therefore substantially worsened for lower income and vulnerable groups. This suggests an urgent need to understand and address how medical insurance coverage may affect CHC service utilization, as it also applies to those who are insured. Outpatient costs in CHCs are usually deducted from the personal saving account, while only inpatient costs can be claimed from the pooled insurance fund. The personal account, however, is quite limited. Therefore, high out-of-pocket payments for health care are common, especially when having chronic conditions that require long-term care such as diabetes and hypertension. It has been reported that people with higher per capita household income tended to report slightly more chronic conditions, probably as a result of unaffordablility and inadequate use of health care. 37 This may prevent the vast majority of more socioeconomically deprived populations from prevention and treatment. One strategy being implemented in China is the expansion of social medical insurance coverage and the reduction of co-sharing in the individual's contribution. 25 , 26 In the UK, it has been shown that greater investments in primary care and targeting poorer areas result in more equity. In China, the reform on the financing mechanisms to optimize healthcare investment in primary care requires long-term investigation on the relationships of primary care cost and patients' experiences to inform healthcare decision-making.

Service utilization

The development of CHCs is expected to alleviate over-utilization of secondary (and tertiary) care through a primary care approach to tackle frequently encountered medical conditions, common minor diseases and chronic conditions at the community level. A detailed service utilization pattern was shown in one large study conducted in southern China. 31 Almost 9 in 10 (85.6%) patients reported a moderate-to-strong affiliation with a regularly visited CHC as their primary care provider. However, as doctor–patient pre-registration is not mandatory, nearly two-thirds of patients chose to visit different doctors within the CHCs. Treatment of acute medical conditions was the most frequent reason for clinic attendance, followed by diagnosis and follow-up of long-term conditions.

Unlike the UK, referral from primary care doctors to hospital specialists (secondary care providers) is encouraged but not mandatory in China. Studies have shown that patients tended to seek services directly at secondary specialist care, 37 , 38 which is likely to be costly and duplicative, compared with primary care. This implied a widened divide between primary care and secondary care in the past decades in China, with secondary care played a dominant role in service provision. The challenge of shifting health system development from specialist care towards generalist community-based care is momentous. The dichotomy between the dual referral channels between primary care and secondary care should be bridged within a properly designed delivery system, such that hospitals could refer patients back to the CHCs for prevention and rehabilitation, instead of keeping a high volume of patients to generate revenue in competition with primary care facilities. Encouraging CHC utilization as the regular source of care through incentives on preferential reimbursement rate at CHCs may serve as an immediate solution. However, a high level of service competency with public trust in primary care is fundamental. Factors that could largely influence the willingness to attending CHCs may also include the familiarity with healthcare staff, communication with doctors, facilities and environment, as well as previous experiences of service utilization. 39–41 This may also require further improvement in CHC service provision within the wider environmental context of personal and social care to address all aspects of wellness of patients' and their family members, encouraging active community participation in the primary care management and priority setting. Studies also indicated considerable room for improvement in job satisfaction with respect to career development, peer recognition, as well as wages and benefits among CHCs workforce to ensure a stable and sustainable development of primary care. 42 , 43

Primary care organizational models

Given the diversified socioeconomic background across urban areas, national policies 14 , 18 , 26 have encouraged local attempts to build up CHCs under different models of ownership and management. Three main categories of CHC models have emerged, including (i) government-owned and -managed CHCs (G-CHCs); (ii) government-owned and hospital-managed CHCs (H-CHCs) and (iii) privately owned and managed CHCs (P-CHCs). 2 , 44 The government report showed that 36.5% of the CHCs were G-CHCs, 35.7% were H-CHCs and 27.8% were P-CHCs. 45 Details on the organizational models were described in both quantitative and qualitative studies elsewhere. 44 , 46 The G-CHCs are organized as part of the government sector. The typical G-CHCs operate in a way that the revenue generated at the CHCs (mainly from medical treatment and drug sales) goes to the local government finance, whereas the CHC expenditures (mainly on premises, equipments and staff remuneration) are paid directly by the local government. The H-CHCs are organized as an affiliated outreach clinical department within the host hospital, in dependent of the government sector. They receive limited subsidies from the government via the host hospital, and the CHC revenue are self-retained and managed, acting as financially self-sufficient healthcare facilities. P-CHCs are built upon social and private investment, managed by private organizations. They are independent of either the government sector or the hospital system and in general hardly receive subsidies from government or hospitals. Financially, self-sufficiency and profit seeking are major characteristics of P-CHCs. These primary care organizational models 44 , 46 reflect a varying extent of government and hospital involvement, and their respective roles in delivering primary care.

The ownership and management models of CHCs and the impacts of this on quality of care have been examined. 44 , 47 Patients with G-CHCs as the usual source of primary care had the highest experience scores compared with those visiting H-CHCs and P-CHCs, as a result of better first-contact care and coordination of care. This suggests that the gatekeeping function of CHCs could be positively enforced by giving preferential reimbursement rates for healthcare episodes for which first attendance is at CHCs. The higher primary care experience score for the coordination domain in G-CHCs implied that the government-dominant top-down approach to delivering primary care was the most effective, particularly at making multi-sectoral service connections between different levels within the health system. Thus, G-CHCs may be able to better solve the problems of constructing primary care services as the first-contact point of care, one of the key conundrums for China's healthcare reforms. 44 It was also reported that patients at G-CHCs were more likely to have optimal blood pressure control, while those with P-CHCs were less likely to achieve blood pressure control, irrespective of the prescriptions of antihypertensive drugs. 47 Thus far, existing evidence suggests that G-CHCs may lead to better primary care process 44 and outcomes, 47 as the model has strengths in that it reduces socioeconomic inequality and results in better distribution of health resources. The recently proposed ‘cloud’ big data plan by 2020 27 is envisaged to illustrate the extent to which primary care physicians follow the clinical practice recommendations and meet guideline targets. 48 To use this effectively will require greater inter-department collaboration, interface exchange between systems and a joint effort involving all stakeholders across healthcare sectors. Further in-depth exploration of primary care organizational models could ultimately lead to the elucidation of how the primary care workforce can be expanded and made more effective in the delivery of primary care in China.

Disease treatment and management

Inappropriate and excessive drug use has been common in China, particularly the prescription of antibiotics without guidance. Data exhibited that the antibiotics on average accounted for more than one-fifth (22.8%) of the total drug sales, and antibiotics were included in more than half of the outpatient visit prescription records. However, only <40% (39.4%) of these prescriptions were deemed properly. 49 New and broad-spectrum antibiotics, combinations of multiple antibiotics, prolonged antibiotic use and intravenous antibiotic administration were favoured, which may lead to many errors in antibiotic usage. 49 Another nation-wide survey illustrated that patients attending G-CHCs were less likely to receive intravenous injection therapies and antibiotics treatments, compared with those receiving prescriptions at P-CHCs. 50 In the G-CHC settings where physicians' salary and CHC revenue from consultations and prescriptions are separate, it is possible that physicians are less likely to prescribe unnecessary drugs. Thus, pharmacotherapy may not be perceived as a must during patient encounters when elevation in blood pressure was only marginal which could be managed with educational and lifestyle modification counselling before drug treatment. 47 , 51 This may reduce the possibility of undesired side effects and complications and thus resulting in favourable clinical outcomes.

The provision of maternal and child care is one of the major functions of CHCs, and the utilization of CHCs instead of secondary hospitals for maternal and child care has been promoted. Most CHCs require community residents to bring their newborn infants for CHCs attendance at scheduled intervals for 6 months after birth, with regular reminders from the community healthcare staff. In contrast, the formal follow-up procedure is generally unavailable at hospital outpatient clinics. Longitudinal data showed that the CHCs could provide better health care, with respect to higher breastfeeding rate and lower prevalence of lower respiratory tract infection, compared with hospital outpatient clinics. 52 The concept of using CHCs as the platform for hypertension management has also been put into practice. Studies have manifested the effectiveness of programmes delivered by CHCs in achieving higher blood pressure control rate and reduced 10-year risk of cardiovascular diseases in community patient population. 53–55

Tackling long-term conditions

China, like many other countries, is also undergoing an explosion in the burden of chronic diseases due to unprecedented economic and environmental changes. Multimorbidity—defined as the co-existence of two or more long-term conditions in one individual—is increasingly common in the UK. 56 Across the globe in China, similar challenges exist and CHCs are expected to be responsible for tackling chronic diseases at the community level. A recent study examined the prevalence of multimorbidity across a selection of 40 chronic morbidities in a large representative sample of the Chinese population. Overall, more than one in 10 of the general population of all ages have multimorbidity, and its prevalence increased significantly with ageing. 37 Unhealthy lifestyle behaviours including smoking, alcohol drinking, salty diet and physical inactivity were commonly reported as risk factors, while ageing, urbanization and increase in prosperity may contribute as underlying key drivers. 7

Similar to western developed countries, the growing issue of multimorbidity in China also leads to greater use of healthcare resources, as shown in a recently published multi-country analysis among China, Scotland and Hong Kong, where the healthcare systems are differently organized. 57 The use of healthcare resources among multimorbid patients was clearly driven by the ability to pay in healthcare system where universal coverage has not yet been established and primary care is still being developed (such as China). The challenge of overcoming healthcare disparities requires strategies that seek to strengthen CHCs and make the primary care universally equitable and effective. 2 , 58 Developing and amplifying the effectiveness of the primary care workforce 59 , 60 should be a top priority, as a properly trained and adequately resourced primary care system could substantially reduce cardiovascular and other risks. 53 At this stage, however, CHCs in China are still far from acting as a first-contact point and regular source of care. The need for a cadre of well-trained and motivated GPs who are qualified from a strong and contextualized education and training system is substantial. 38 , 61 , 62

Strengths and weaknesses of the review

In this review, we outlined the development of urban CHCs under the national health care policies with respect to the CHC structure and delivery models, and the impact of primary care reform on key issues based on the most recent empirical evidence. There are several limitations. First, a comprehensive meta-analysis synthesizing quantitative data was not performed due to limited number of studies included for each outcome in this review. Second, the information published in Chinese language were only retrieved from central government documents and official statistics wherein major progress of primary care was fully documented with high-quality evidence. Third, the complexity of China's healthcare system may affect the generalizability of the findings reviewed as national policy implementation could be decentralized at provincial authorities. It is also worthy of note that themes covered in this review were based on panel discussion, and thus, selection bias may exist, albeit the searches of literature were conducted in a systematic manner. Nevertheless, a wide range of topics were highlighted, including CHC structures, human resources and financing, service utilization, primary care organizational models, patients' experiences, antibiotics use, hypertension management, improvement of maternal and child care, where rapid development has been observed.

The past decade has witnessed a journey of booming development in primary care and laudable achievements in building the CHC infrastructure with sustainable policy support in China. The road towards a strong primary care-led system is promising but challenging. The rapid escalation of healthcare costs with incomplete coverage of medical insurance may partly lead to the inequality in primary care experiences. The vast regional differences with substantial divides in health between socioeconomic strata require quality primary care to reduce healthcare disparities, especially in light of an ageing population and emerging burden of multimorbidity. Despite progress, primary care is still weak in China. The trade-off between governments and markets under China's decentralized healthcare system will largely determine the extent to which primary care promotes health equity and service cohesion. Enhancing CHCs as the first-contact point and regular source of equitable care for patients with respect to the key quality attributes including first contact, coordination, continuity, comprehensiveness, as well as family and community centredness would appear to be a top priority.

S.M.G. conceived this review and provided overall guidance. H.H.X.W. and J.J.W. reviewed the Chinese government documents and official statistics from 1997 to September 2015. H.H.X.W., J.J.W., S.Y.S.W. and M.C.S.W. contributed to the literature search in NCBI PubMed. H.H.X.W. wrote the first draft. All authors (H.H.X.W., J.J.W., S.Y.S.W., M.C.S.W., S.W.M. and S.M.G.) contributed to the feedback on review results and writing of the final report.

Supplementary material is available at BRIMED online.

The authors have no potential conflicts of interest.

We wish to acknowledge the support from the Department of Health, Guangdong province, P.R. China (C2009006/2009-2013); Department of Education, Guangdong province, P.R. China (BKZZ2011047/2010-2013); New Faculty Start-Up Research Fund, Sun Yat-Sen University (51000-31121405); and Community Health Research Fund, Community Health Association of China, P.R. China (2012-2-91). We also thank Professor Liang Xu at Guangdong General Practice Education and Training Centre, P.R. China, for her valuable advice on the review of primary care official guidelines and document milestones. J.J.W. is supported by Guangdong Exemplary Centres for Exploratory Teaching in Higher Education Institutions—General Practice Exploratory Teaching Centre (GDJG-2010-N38-35, Guangdong Department of Education, P.R. China), and The Ninth Round of Guangdong Key Disciplines—General Practice (GDJY-2012-N13-85, Guangdong Department of Education, P.R. China), both of which he leads. H.H.X.W. was supported by a postdoctoral research fellowship in the Hong Kong–Scotland Partners in Post Doctoral Research programme, Research Grants Council of Hong Kong and the Scottish Government, UK (S-CUHK402/12). The Scottish School of Primary Care, part-supported SWM's post and the development of the National Research Programme on Multimorbidity, which he leads.

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India's Public Health Care Delivery pp 217–258 Cite as

Structure and Function I: The Primary Health Centres

• Sanjeev Kelkar 2  
• First Online: 06 March 2021

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The history and evolution of the primary care concepts, its inability to discharge the functions well in the given or suggested structures in the PHC is discussed. The inseparability of the sub-centre community health care and hitherto neglected secondary curative health care to the community is emphasized. The need to segregate the curative and the preventive health care functions, taking these two to a much expanded CHC structure and its functional profile is discussed. The major recommendation of simultaneous systematic phased closure of four PHCs for the creation of one CHC out of five is made; the likely objections are answered. The relocation of PHC workers and ease with which it can be done is emphasized. Entry of variety of professionals and services in the area of closed PHC and its beneficial effects are described.

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The rationale behind closing dysfunctional structures came for me from Mr. D. R. Pendsey, the then advisor of the TATA Group in 1984. He had a clear message which I have not forgotten till date. ‘The governments should be lean. Then only they can be agile. Then and then only it can become highly effective.’ Two practices interfere with this attempt. One is the multilaterality and the multi-authority that the government, or more precisely the IAS cadre, builds deliberately. The second philosophical issue is to spread everything widely in the name of equity and justice which it does not deliver. Then large-scale restructuring with newer forms with abilities to deliver is imperative and should be able to show the power and effectivity to deliver durable results, which can then build confidence among the people.

From 1989 till 2006 and even later, when we tried to talk about the curative services with activist friends, in forums organized by them, the idea did not receive any appreciation. It was either brushed aside or politely avoided, since it did not come in the realm of primary care. On two occasions I had a distinct feeling that the problem-solving capacity of what I was proposing was so high that the theorists literally blocked it so that the problems remain unsolved. Instead of reacting to such treatment meted out, we continued to introspect on what we thought was correct, though we were disappointed and dejected by the treatment the ideas received.

It must also be recognized that the new government in the centre has done much more from mid-June 2014 till mid-2017 than was expected in drug pricing. It has shown courage in throwing off the yoke of irrational combinations and opened generic medicine shops. The chain reaction of it benefitting the patients and even the pharmaceuticals in the long range is discussed in the second volume mentioned above. The government system, the National Pharmaceutical Pricing Authority (NPPA), was gripped with general apathy, listlessness, indifference on price regulations, which has now been corrected.

After demonetization, tracking and action on defaulters has gained momentum. As part of the process, the government has managed to shut out a couple of hundred thousand shell companies which has been well publicized. Hopefully, it will reduce the wholesale crony capitalism to fewer recognizable players of the power corridors. There were 433 government schemes under 56 ministries in 2017 which must have gone up by 2021 for direct bank transfers to the beneficiaries which have eliminated the difficulties in getting the money through the middlemen and agencies, saving human effort, money lost between and ensured full payment.

The ridiculous ways a government can resort to, to fill vacancies will be clear in the instance mentioned here. On July 22, 2017, Maharashtra government issued a circular to all the allopathy doctors who had passed from the state colleges in Maharashtra, not just the newly passed but as old as those who passed out 25 years ago. It demanded that we must submit our bond certificate when we passed out to see who had not done the compulsory rural service as the bond had demanded. If it was not done, our names would be removed from the state medical council. This was being done to fill up all the vacancies in the state public health service by forcing us to leave what we were doing.

It is an additional issue whether the new  AYUSH graduates deployed here have enough mastery of their own pharmacopeia they are to use.

In June 2015, the transport commissioner of Pune stopped salaries of the Repair and Maintenance Depot officers of government transport vehicles, mainly buses, demanding an explanation as to why 300 buses were idle? Within a month 60% buses were plying on the roads, with more to follow. (To note: the commissioner has been picked up by the Prime Minister’s Office (PMO) in New Delhi.)

This will be discussed again in the chapter on urban poor in greater detail.

The quacks are no small matter. In the early 1990s in a then industrializing city in Maharashtra, the only doctor who gave human insulin to people with diabetes was a quack, who assured people of restoring the erectile dysfunction common in diabetes. Some MDs in allopathic medicine were later trained by the pharmaceutical giant Novo Nordisk in diabetes who then started the use of human insulin.

The drivers are useful in doing different work in mobile camps and for the large-scale activities in a project. In a government system, such motivation and involvement is not likely to fructify. The general experience is that all the intrigue starts with a driver in a set-up, engaged or idle. It is the culture that needs to be changed.

In 1976, I met a leader of the Bus Conductors Union in Mumbai, who mentioned to me that most conductors, as they begin the day, put their hand to the landing of the bus, place it on their heart and then climb up. No one builds on such sentiments.

As an example, I may point out my own experience using methods of involving quacks and teaching them. It has met with gratifying response in West Bengal Villages from 2011 to 2013.

There is a large-scale network of agriculturally related activities using connectivity, sophisticated beyond common perception, the semi-literate people are using with alacrity in a backward district of Yeotmal in Maharashtra, where ITC has established choupals , something like a temporary storage and movement of goods. These services have been used to transport blood samples and carry the reports back to villagers. Reuters have similarly established an online system in villages for agricultural information transmission which can be used for health communication. With digital India going full swing, the connectivity should not be a major issue in times to come.

Duggal Ravi, Gangolli Leena, 2005, Ed Review of Health Care,CEHAT, Mumbai.

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Shanthi Dr, Director of preventive health Kandy, Sri Lanka, in personal interview on 28th November 2018.

Wanigatunge C. Prof, Clinical Pharmacology and medicine, University of Jayavardenapura, Sri Lanka in personal interview on 2 nd December 2018.

Rural Health Statistics of 2014, Government of India.

PTI | July 02, 2017, Economic Times Health World.

Services PHCs IPHS standards 2012, Ministry of Health and Family Welfare GoI.

Warner, David circa 1980, Where there is no Doctor.

Diggikar Ranjana | 08 July 2015, 8:14 AM IST ET Health World Newsletter.

Indian Public Health Standards (IPHS) Guidelines for Primary Health Centers 2012.

Lele Dr Bagaram, 2015, Long serving employee of Mumbai municipal corporation, Personal Communication.

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Kelkar, Sanjeev, 2021  India’s private health care delivery: Critique and remedies , Palgrave Macmillan India.

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Assessment of the implementation of health education in primary health care facilities, Kavango, East Region, Namibia

Filippine n.nakakuwa.

1 Master in Public Health, University of Namibia, Windhoek, Namibia

Marian T. Sankombo

Emmanuael magesa.

2 Faculty of Health Sciences, Welwitchia University, Namibia

Contributions: the authors contributed equally.

Primary Health Care (PHC) facilities are critical in preventing, detecting, and managing sickness and injury, thereby lowering morbidity and mortality. This is easily accomplished through health education, which is one of the most effective disease prevention methods.

The goal of this study is to evaluate the implementation of the health education technique in PHC facilities in the Kavango East Region.

Materials and Methods

A quantitative method was used in conjunction with a descriptive cross-sectional design to evaluate the implementation of health education in PHC facilities in the Kavango East Region.

The outcomes show that 76% of patients who visit health facilities did not receive health education about their condition, and those who did receive health education know six times more about how to prevent the conditions they are suffering from than those who did not. The study also found that 49.14% of patients got information that was irrelevant to their conditions. These results indicate a statistically significant relationship (2.32 OR 0.93 at 95% CI) between patients who did not receive health education and frequent visits to the PHC facility with the same complaints.

There is a lack of health education implementation in PHC facilities, with patients not getting or being provided with relevant health education to empower them to take care of their own health. The emphasis of PHC centers is on curative services rather than preventative and rehabilitation services. PHC facilities must improve health education as a critical approach to health promotion and disease prevention. This will allow patients to take appropriate preventive measures, resulting in fewer trips to PHC facilities.

Introduction

In 1977, The World Health Assembly recognized that the main goal of the World Health Organization (WHO) should be to ensure that all people achieve a level of health that permits them to lead socially and economically productive lives. The Alma Ata conference (1978) defined Primary Health Care (PHC) as the key to achieve health for all by the year 2000. In order to provide a basis for understanding primary health, a definition of PHC was established at the National Forum on Health in 1997. 1 , 2 Primary Health Care is understood to be “the care provided at the first level of contact with the health care system, the point at which health services are mobilized and coordinated to promote health, prevent illness, care for common illness, and manage health problems”. 3 , 4

PHC is the area of the health care system most suited to offering primary prevention and health promotion activities as it is easily accessible, provides continuity of care, and is used by a large proportion of the population. Primary Prevention and Health Promotion activities include initiatives to maintain or increase the level of wellness and to reduce risk factors associated with distinct diseases through the promotion of lifestyle changes ( e.g. , healthy eating, physical activity, or smoking cessation) and prevention of physical and mental disease such as cardiovascular diseases or depression. 5 PHC professionals have many opportunities to promote healthy behaviors in patients with effective interventions. 6

The core functions of the PHC Directorate in Namibia are guided by the WHO/Primary Health Care approach and the Declaration of Alma Ata of 1978. The Declaration emphasizes four pillars as reflected in the Namibian PHC House. These are: health promotion, disease prevention, curative and rehabilitative services. 7 Health promotion is one of the four principles of primary healthcare that would save more lives of people if implemented at all primary healthcare entry points. Health promotion measures are often targeted at a number of priority diseases – both communicable and non-communicable. The Millennium Development Goals had identified certain key health issues, the improvement of which was recognized as critical to development. These issues include maternal and child health, malaria, tuberculosis and HIV, and other determinants of health. 8 Health promotion has a holistic approach to promoting health intervention to stimulate the health and wellbeing of society, i.e. , proper nutrition and physical activities, preventing diseases, identification and maintaining the health of persons suffering from chronic illnesses. 9 Emphasis on the prevention of diseases and health promotion services provides an opportunity for demanding and establishing health promotion services in hospitals. Therefore, because of their central role in providing health services in the community and their interaction with different categories of patients, staff and organizations have great potential to influence health promotion services and provide these services. 10

One of the primary functions of front-liners in all PHC facilities is to equip the community/society with the necessary knowledge and skills to become self-reliant in terms of disease prevention and health promotion. The Ministry of Health and Social Services (MOHSS) has embarked upon a series of training on health education since independence. 11 Despite, the efforts by MOHSS, still PHC facilities are overcrowded daily by patients visiting PHC facilities for various preventable diseases ranging from simple Upper Respiratory Tract Infections to Sexual Transmitted Infections. Furthermore, the MOHSS’ health information system is still recording cases of such preventable diseases in the country monthly. 7 In the absence of effective implementation of health promotion services at PHC facilities, the country may experience a high incidence of preventable diseases, outbreaks of communicable diseases, high outpatient turnover, and increased staff workload. Therefore, there is clear evidence that the implementation of PHC strategies such as health education needs to be assessed.

The aim of this was to assess the implementation of the health education strategies in Primary Health Care facilities in Kavango, East Region.

Ethical clearance and informed consent

The research proposal was approved by the Ethics and Research Committee of the University of Namibia. Permission to conduct the research was obtained from the Ministry of Health and Social Services. The purpose and procedures of this study were explained to all the participants, who gave informed consent before data were collected.

Study population and study sample

A descriptive cross-sectional design to assess the implementation of health education in Primary Health facilities in Rundu, Kavango East. The population of this study was all patients and guardians of all children with preventable health conditions visiting the PHC facilities seeking curative services. A total sample of 368 was obtained and a stratified disproportionation fraction was used.

Research instrument

The researchers and trained student nurses collected the data by administering a structured questionnaire to participants. The study was voluntary, whereby the content of the questionnaire was explained to participants before they gave permission to participate. The questionnaire was translated in orukwangari, the most spoken language in Kavango East, for participants that do not speak English. The questionnaire assesses whether patients that are treated in the PHC facilities are given health education, the content, and how it was given. The questionnaire was divided into three sections: section A contained demographic data (communicable/ non-communicable); section B contained content of health education given and section C asked what types of health promotion/ education materials ( e.g. , pamphlets, posters, cards) were given during health visits.

Data were analyzed using Epi info, version 7, in which simple logistic regression was used to show the relationship between the provision of health education and health outcome.

The quantitative results of this study focused on demographic data and assessment of the implementation of health education at PHC facilities in Kavango East region.

Demographic profile

A total number of 313 participants participated in this study from a sample size of 368 using the structured questionnaire, making a response rate of 85%.

The number of patients who visited PHC facilities in the Kavango East region (n=313) ( Figure 1 ). Most of the participants (n=80, 25.72%) were females aged between 21-25 years. And few (n=16, 5.14%) males aged 26-30 years participated in the study.

Statistics on health education

From Table 1 , the findings indicate that OR is 6.15 (OR 3.73 < 6.15 < 10.14). At the same time, a Chi-square is 54.48% with a Pvalue <0.01. This indicates that patients who received health education knew how to prevent the conditions they were suffering, six times more than those who did not receive health education.

Demographic information (n=313).

Table 2 indicates that n=57, 49.14% of participants who received health education regarding their medical conditions, the information was not relevant to their conditions. However, almost the same n=59, 50.86% of patients indicated that the health education given was relevant.

From Table 3 , the findings (2.32< OR <0.93 at 95% confidence level) show that there is a statistically significant association between patients who were not given information regarding their medical condition and the patients who come back to the health facility with the same complains as the previous one.

Most participants were female (62%) compared to their male counterparts (38%). In general, women are more likely to visit health facilities the doctor than men. These findings relate well with Berkowitz, 12 whereby 84% of female patients in his study visited the general practitioner than male counterparts, 66% in Canada. Similarly, in USA, 80% of males visited health facilities in relation to 89.5% of females. 12 These finding does not represent statistical significance on why women are visiting health facilities very often, but it is believed that, generally, the population of females outnumbers males, and females are more likely to visit health facilities than their male counterparts because women are exposed to a wide variety of health services than men. For example, females may visit, health facilities to seek medical attention as well other services i.e. , antenatal services, annual breast/cervical examinations, antenatal, peri and postnatal care visits, and many more.

Impact of the health education given at the primary health care facilities

Health education is one of the strategic actions in the health sector that aims to promote good health practices among communities. It is part of the comprehensive healthcare strategy developed by the primary health division in the MOHSS in Namibia. This study revealed that 76% of the patients that visited PHC facilities in the Kavango East region, Rundu district, did not receive health education regarding their conditions, and yet, 76% did not know how to prevent the diseases they are suffering from. It is expected that any patient who receives health education on any condition must possess some insight on how to prevent that condition, in order to prevent that particular patient from returning back to the same or different health facility for the same condition. If all patients receive health education on conditions that they are suffering from, they should be able to prevent such conditions and improve their health. The main responsibility of healthcare workers is to improve public health and motivate patients to take care of their own health through health education. 13 The practice of primary health care workers cannot be effective without proper implementation of health education. 14 Therefore, healthcare workers (HCWs) must play a role of a health educators and are expected to act as a source of information and create an expectation that HCWs possess current and relevant information related to both communicable and non-communicable diseases. 15

Impact of the health education given at the primary health care facilities (n=310).

The P-value is set at 0.01, at 95% confidence interval.

Relevance of health education given to patients at primary health care facilities in Kavango East (n=313).

Number of patients that were treated with the same condition within 12 months.

Relevance of health education

The findings of this study revealed that 49.14% of patients who visited health facilities received information that was not relevant to their condition. Although 50.86% of patients received relevant information, the percentage of patients who received irrelevant information is worrisome. Of course, it is important to provide general information that aims at improving the general well-being of a person but then health workers should also pay attention to the current problem as this will prevent the patient from repeatedly seeking health care services for the same condition. The findings indicated challenges regarding the provision of health education, whereby patients are receiving general health information rather than receiving focused information based on their current conditions. The findings agree with the study conducted in South Africa by Visagie and Schneider, 16 whereby the care in the setting was not client-centered, and individual users were not enabled to allow them to manage their conditions. The result of this study gives an indication that the services offered are more curative services rather than preventative and rehabilitative. Some scholars have investigated the effect of health education on the prevention and control of respiratory infectious diseases in school students. His study found that the awareness of respiratory knowledge and the formation rate of healthy behavior of primary and high school students in the intervention group were significantly improved after the health education. 17 , 18 This underscores the benefits of health education in changing the health behaviors of the community toward disease prevention. Patients who receive information regarding their medical condition are more likely not to come back to the health facility with the same complaints, simply because they are well-informed on how to change their lifestyle and prevent the same illness. This may reduce the financial burden on the state as well as individual patients, as this will minimize hospital visits for preventive ailments.

Patients tend to come back with the same health problems because they are not well informed regarding immunization, communicable diseases control, environmental health, nutrition, school health services, first aid services, drug education, accident prevention and emergency, services, and aid family life education. Therefore, health education needs to be strengthened to minimize the higher volume of patients coming to health facilities and eventually reduce nurses’ workload.

The only limitation of the study was the sample size; according to the sample size calculations, 368 respondents were supposed to participate in the study, but the researchers managed to collect data from 313 participants, which was 85%.

Conclusions

The study concluded that health education as one of the principles of primary health care services is not implemented successfully. The fewer patients that receive health education are unable to utilize the information received from health workers to take care of their own health. No community health education programs provide information to community members to make an informed decision on communicable disease prevention. Health workers at the facilities are overwhelmed with a lot of work and focused more on curative than health education and diseases prevention. Our recommendations are that MOHSS should ensure that health education is a strengthened part of PHC services through ongoing in-service training of health educators for effective PHC services in Namibia; health education should be provided for the community members, regardless of how busy the health facilities are, so as to the community members to have rights to health and preventing communicable diseases; the information provided to the community should also focus on the current health conditions that the patients are suffering from.

Acknowledgments

The authors would like to thank all the participants who took the time to participate in the study; without their participation, this study would not have been possible. We also thank the Ministry of Health and Social Services and the University of Namibia, Rundu Campus, for granting the permission to conduct research.

Funding Statement

Funding: none.

• Open access
• Published: 15 March 2024

Systematic review and meta-analysis of physical activity interventions to increase elementary children’s motor competence: a comprehensive school physical activity program perspective

• Jongho Moon 1 ,
• Collin A. Webster 2 ,
• David F. Stodden 3 ,
• Ali Brian 3 ,
• Kelly Lynn Mulvey 4 ,
• Michael Beets 5 ,
• Cate A. Egan 6 ,
• Lori Irene Flick McIntosh 7 ,
• Christopher B. Merica 8 &
• Laura Russ 9  

BMC Public Health volume  24 , Article number:  826 ( 2024 ) Cite this article

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Regular participation in physical activity (PA) benefits children’s health and well-being and protects against the development of unhealthy body weight. A key factor in children’s PA participation is their motor competence (MC). The comprehensive school physical activity program (CSPAP) framework offers a way to classify existing PA interventions that have included children’s MC development and understand the potential avenues for supporting children’s MC. However, there have been no systematic reviews or meta-analyses of PA interventions and their effects on the MC of elementary school children (aged 5–12 years) from a CSPAP perspective.

This study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We searched seven electronic databases (PubMed/Medline, Embase, ERIC, SPORTDiscus, CINAHL, Web of Science, and PsycINFO) for articles on 29 November 2021. The CSPAP framework was used to categorize the different intervention approaches. This review was registered with PROSPERO (CRD42020179866).

Twenty-seven studies were included in the review, and twenty-six studies were included in the meta-analysis. A wide range of PA intervention approaches (e.g., single component or multicomponent) within the context of the CSPAP framework appear to be promising pathways in enhancing children’s MC. The results of the aggregate meta-analysis presented that effect sizes for the development of MC from pre-and post- intervention ranged from moderate to large (Hedges’ g  = 0.41−0.79). The analysis revealed that the predicted moderators, including study length, delivery agent, and study design, did not result in statistically significant moderate variations in MC outcomes. There was, however, considerable heterogeneity in study design, instruments, and study context, and studies were implemented in over 11 countries across diverse settings.

Conclusions

This study uniquely contributes to the literature through its primary focus on the effectiveness of PA interventions on elementary children’s MC. This review emphasizes the importance of customizing CSPAP to fit the specific characteristics of each school setting, including its environmental, demographic, and resource attributes. The effectiveness of CSPAP, particularly its physical education (PE) component, is significantly enhanced when these programs are adapted to address the unique needs of each school. This adaptation can be effectively achieved through targeted professional teacher training, ensuring that PE programs are not only contextually relevant but also optimized for maximum impact in diverse educational environments. Researchers and practitioners should pursue how to effectively translate the evidence into practice to better conceptualize CSPAPs designed for children’s MC development.

Peer Review reports

It is well established that physical activity (PA) is crucial for the healthy growth and development of children [ 1 , 2 ]; however, many children are not sufficiently active. Globally, over 85% of children and adolescents are not meeting the World Health Organization’s (WHO) recommended PA guidelines [ 3 ]. These guidelines suggest that children and adolescents should engage in at least 60 min of moderate-to-vigorous (MV) PA daily [ 3 ]. This level of activity is considered essential for maintaining physical health, supporting development, and fostering overall well-being in young individuals. Motor competence (MC) plays a major role in children’s PA participation [ 4 , 5 , 6 , 7 , 8 ]. MC can be defined as the capability to perform a wide range of motor acts or skills and involves both locomotor (e.g., running, jumping, and skipping) and object projection (e.g., throwing, catching, and kicking) skills [ 9 ]. The development of MC during childhood is crucial for a healthy life since it allow individuals to successfully participate in lifetime physical activities [ 4 , 7 , 8 ]. According to Stodden et al. [ 7 ], the attainment of adequate PA and MC levels should be viewed using a developmental perspective. In other words, children with greater MC were observed to spend more time in moderate-to-vigorous PA [ 10 ], whereas those with less developed MC appeared less physically active [ 4 , 6 ]. Longitudinal evidence suggests that having higher levels of MC during childhood is associated with being more physically active later in life [ 11 , 12 , 13 ]. Conversely, low MC is hypothesized to result in decreased participation in PA in middle to late childhood, thus leading to a negative spiral of disengagement from an active lifestyle [ 7 , 8 ].

Developing children’s and adolescents’ MC is a primary goal of physical education (PE) and is considered foundational to promoting lifetime participation in PA [ 14 , 15 ]. Particularly during the elementary school years, establishing a robust foundation in MC is crucial as it facilitates the transition to more specialized movement forms in organized games and sports [ 16 , 17 ]. This foundational stage involves the development of fundamental movement skills (FMS), which encompass a variety of basic movement patterns including locomotor skills, objective control skills, and stability skills [ 18 ]. These skills are essential building blocks for more complex and specialized motor skills acquired later in life [ 9 ]. Regular involvement in context-specific and developmentally appropriate PA experiences is critical [ 18 , 19 , 20 ]. The development of MC does not occur “naturally” and requires sufficient practice and experiences to successfully apply essential skills in the various PA activities that require their application [ 20 , 21 ]. However, focused programming to support children’s MC development is decreasing for school-aged children, in tandem with a downward trend in the prevalence of PE [ 22 ]. It therefore becomes vital to explore and learn from innovations in school-based programming, which can not only counteract the declining provision of PE but also present expanded opportunities for children to develop their motor skills.

Recently, there has been increased interest in what the Institute of Medicine in the United States called a “whole-of-school” approach to PA promotion in children and adolescents, in which PA opportunities are provided before, during, and after school through the support of school staff, families, and community partners [ 23 ]. The International Society for Physical Activity and Health (ISPAH) named whole-of-school PA one of eight investments that work for increasing PA [ 24 ]. McMullen et al. [ 25 ] provide an insightful analysis of whole-of-school PA initiatives undertaken in Finland, Ireland, Poland, and the United States. Common to these initiatives is a focus on multiple PA opportunities, contexts, and promotion agents that coalesce around a strong PE program and build upon it with additional PA. While much of the attention given to whole-of-school PA centers on the extent to which such an approach can support children’s attainment of 60 min of PA each day (in line with current guidelines) [ 26 , 27 , 28 , 29 ], the contribution of expanded PA opportunities to the development of children’s MC also warrants investigation. If designed appropriately, PA opportunities beyond PE may allow children to apply and practice what they learn in PE and continue to develop their motor skills [ 30 ].

A plethora of review studies have substantiated the beneficial impact of PA interventions on the enhancement of MC among children and adolescents, as evidenced by research such as Lorås [ 31 ] and Zeng et al. [ 32 ]. Notably, Barnett et al. [ 33 ] undertook a systematic review of longitudinal data pertaining to MC and health, elucidating the interplay between MC and health outcomes (e.g., weight status, health-related fitness). Complementing this, Han et al. [ 34 ] and Hassan et al. [ 35 ] independently deduced that exercise and PA interventions markedly improved FMS and motor coordination in children and adolescents, with aerobic activities showing pronounced efficacy in augmenting object control and gross motor skills. Ruggeri et al. [ 36 ] further corroborate this viewpoint, demonstrating that interventions focusing on motor skills and PA fostered enhanced participation, activity, and improvements in body structure and function in children diagnosed with autism spectrum disorder. Conversely, Jones et al. [ 37 ] present a caveat, highlighting that despite the established positive correlation between PA and motor skills in early childhood, the exact causative directionality of this relationship remains an area of ambiguity.

Overall, there is substantial evidence supporting an association between PA and MC, but less is known about the development of children’s MC in the context of whole-of-school PA approaches. The current review aims to bridge this existing knowledge gap by synthesizing and evaluating the collective impact of PA interventions while considering how these interventions align with whole-of-school PA promotion. For the purposes of this review, we have adopted the comprehensive school physical activity program (CSPAP) model as a representative whole-of-school PA framework. In the United States, the Centers for Disease Control and Prevention (CDC) named the CSPAP model as the national framework for school-based PE and PA [ 1 ]. The model includes five components: (a) quality PE, (b) PA during school (DS), (c) PA before and after school (BAS), (d) staff involvement (SI), and (e) family and community engagement (FCE) [ 1 , 38 ]. This study will dissect the nuances of how various PA interventions, categorized under CSPAP components, distinctly influence MC outcomes in elementary school children. The purpose of this study, therefore, is to conduct a systematic review and meta-analysis, based on CSPAP framework, of the effectiveness of PA interventions in increasing the MC of elementary school children (5–12 years). By doing so, it endeavors to offer a refined perspective on PA’s role in enhancing MC, thereby setting the stage for more effective, tailored CSPAP program implementations in the future. Ultimately, this systematic review and meta-analysis seeks not only to consolidate the existing research but to push the boundaries further in understanding and optimizing the role of PA in the development of children’s MC.

Registration and protocol

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 39 ] with additional recommendations for systematic meta-reviews [ 40 ] and was registered with the International Prospective Register of Systematic Reviews at https://www.crd.york.ac.uk/prospero/ (registration number CRD42020179866).

Inclusion/eligibility criteria

Studies with the following characteristics were included in our review:

Participants were aged 5–12 years (primary/elementary school);

PA interventions primarily focused on improving and assessing MC/FMS components;

Type of interventions: Any school-, home-, or community-based interventions for children with clear intent to improve MC/FMS proficiency;

Type of studies: Employed a Cluster-Randomized Controlled Trials (C-RCTs) design, RCTs, or rigorous (matched or statistically controlled) quasi-experimental design.

Exclusion criteria

Studies with the following characteristics were excluded from the review:

Studies that reported on a population of focus outside of the age range defined above; or participants who were not ‘typically developing’ (i.e., had a clinically diagnosed physical or intellectual disability or condition affecting movement, e.g., autism, visual impairment, cerebral palsy, traumatic brain injury/concussion);

Studies that did not aim to improve and assess at least one of MC/FMS components outcomes were excluded;

Studies reported as abstracts, theses/dissertations and unpublished literature were excluded.

It should be mentioned that our search was not limited by the CSPAP framework, since the framework incorporates all conceivable circumstances and opportunities for PA promotion for children. Additionally, we aimed to include all relevant PA interventions regardless of whether the researchers used the CSPAP framework explicitly in their published publications. Thus, we did not perform our search using the phrase “CSPAP” or variants of the terms (e.g., comprehensive PA, whole-of-school PA).

Search strategy and terms

The studies were obtained on November 29, 2021 using seven electronic databases: PubMed/Medline, Embase, ERIC, SPORTDiscus, CINAHL, Web of Science, and PsycINFO. The search strategy consisted of four elements: study population (e.g., elementary school student), study design, intervention (e.g., PA and exercise), and outcome measures (e.g., MC; see detailed search strategy in Supplementary Table 1). The search was limited to peer-reviewed academic journal articles published in English in all available years.

Data extraction/collection process

Data were imported into Endnote X9.3 (The Thomson Corporation Corp, Stanford,

CT, USA) and duplicates were removed. The selected references were imported to a web-based software platform that streamlines the production of systematic reviews (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia, available at www.covidence.org ). This first level of screening, two independent reviewers (CAE and CBM) screened the titles and abstracts of retrieved records for possible inclusion. Of the records identified as possibly eligible, the full texts were obtained, and two independent reviewers (LF and LR) assessed the records for inclusion. For each included study, two reviewers (CAE and LF) extracted data into a pre-defined Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) data collection form. Data were extracted on the following: type of study design; the intervention approach, based on the CSPAP framework; the sample size; the intervention characteristics including session duration, frequency, length, delivery, and the name of programs; the types and methods of measured outcomes including the specific instrument; the fidelity of implementation measure; and the main results. For all steps in the screening process and data extraction, a third reviewer (JM or CAW) checked the data for errors, and discrepancies were resolved through discussion and consensus of judgement. If data were missing, authors were contacted.

Qualitative data synthesis

Extracted results showed information including the article reference, study design, intervention approach (i.e., CSPAP components used), study characteristics (country, school setting, school level, name of the intervention program, participants, intervention deliverer, and MC outcomes), dose, main results, and implementation fidelity reporting. Results were organized into three sections by: (1) study design (i.e., C-RCT/RCT and N-RCT), (2) interventions addressing a single CSPAP component (i.e., PE, PADS, PABAS, and FCE) and (3) interventions addressing multiple CSPAP components (e.g., PE + 1 additional component and PABAS + FCE).

Quantitative data synthesis

Effect sizes were calculated for the intervention group relative to the comparison group for each study. When the necessary data were not available in the original article, we requested it from the authors. If data could still not be obtained, we extracted the data from the graphs when available. If that was not possible, we excluded the study from the quantitative analysis. A meta-analysis for a given MC outcome was conducted if at least three studies reported interventions addressing the same CSPAP components and provided sufficient data for the calculation of effect size.

Pre- and post-intervention mean ± standard deviation (SD) for a given MC outcome, and sample size from each study were converted to Hedges’ g effect size [ 41 ]. Specifically, we calculated standardized mean differences both for outcome scores at the end of the intervention period (post-intervention) and change-from-baseline (pre-intervention) outcomes. Scores post-intervention effect sizes refer to intervention group results compared with comparison or control group results after interventions. We did not include follow-up assessment data. In all analyses, we used the random-effects model to account for differences between studies that might impact the treatment effect [ 42 , 43 ]. The effect size values are presented alongside their respective 95% Confidence Intervals (CIs). Calculated effect sizes were interpreted using the following scale: small ( g  < 0.40), moderate ( g  = 0.40−0.70), and large ( g  > 0.70), according to the Cochrane Handbook [ 44 ]. Heterogeneity (i.e., between studies variability) was evaluated using the I-squared ( I 2 ) statistic. I 2 values of < 25%, 25−75%, and > 75% were considered to represent low, moderate, and high levels of heterogeneity, respectively [ 45 ]. The risk of bias was explored using the visual inspection of funnel plots and Egger’s regression test [ 46 ]. Publication bias was not produced as the meta-analyses included < 10 studies/interventions [ 47 ].

A series of models were analyzed to address the following: (1) the pooled effect of PA interventions across all studies on elementary school age-children’s MC (overall and by measurement), (2) the pooled effect of interventions using only PE compared to the pooled effects of other single-component interventions that did not use PE (PADS only, PABAS only, and PADS + PABAS + FCE) on children’s MC, and (3) the pooled effects of interventions using PE plus additional CSPAP components (PE + 1 and PE + 2) on children’s MC. In addition, moderation analyses were performed to explore the impact of potential explanatory variables and moderators (intervention duration [< 6 months vs. ≥ 6 months], delivery agent [research team vs. school-based team vs. combined], and study design [C-RCT/RCT vs. N-RCT]) on the effect sizes with meta-regressions when sufficient data were available (i.e., at least ten studies for each explanatory variable) [ 44 ]. The results were expressed as regression coefficients estimates, 95% CIs and the p-value. All analyses were carried out using the Comprehensive Meta-Analysis program (version 3.3.070; Biostat, Englewood, NJ, USA). The statistical significance threshold was set at p  <.05.

Risk of bias assessment

Risk of bias in the included studies was assessed by two reviewers (JM and CAW) independently through discussion using the Cochrane Risk of Bias Tool (RoB 2.0) with additional considerations for C-RCTs and RCTs [ 48 ], which consists of five domains and an overall judgment [ 40 ]. The five domains are: (1) bias arising from the randomization process; (2) bias due to deviations from the intended interventions; (3) bias due to missing outcome data; (4) bias in measurement of the outcome; and (5) bias in selection of the reported result. Based on the answers (yes, probably yes, probably no, no, not applicable, no information) to a series of signaling questions in the guidance document, the judgment options within each domain consist of “low risk of bias,” “some concerns”, or “high risk of bias” [ 48 ].

The N-RCT (i.e., quasi-experimental) studies were assessed with the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool [ 49 ], which consists of seven domains and an overall judgement. The seven domains are: (1) bias due to confounding; (2) bias in selection of participants into the study; (3) bias in classification of interventions; (4) bias due to deviations from intended intervention; (5) bias due to missing data; (6) bias in measurement of outcomes and (7) bias in selection of the reported result [ 49 ]. Domain-specific risk of bias assessment was used to judge the overall risk of bias for each study. Disagreements between reviewers were resolved through discussion and consensus by a third evaluator (CAE). Before correcting for observed differences, the agreement between reviewers was assessed using a Kappa correlation for risk of bias (κ > 0.8). A risk of bias graph was made via the robvis R package [ 50 ].

A total of 6,064 search records were initially identified. The authors screened 3,804 records after removing duplicate records. This first level of screening, separated by title and abstract, identified 439 full-text articles to be reviewed for eligibility. Ultimately, of the remaining 286 articles, 27 studies were included in the qualitative synthesis and 26 studies were included in quantitative synthesis. The process of literature identification and selection is outlined in the PRISMA flowchart (Fig.  1 ). The quality assessment for C-RCTs or RCTs revealed five studies as low risk in quality, four studies as having some concerns in quality, and one study as high risk (Supplementary Fig. S1 ). For N-RCTs, nine studies were evaluated as low risk of bias, six studies as moderate quality, and two studies as serious risk of bias (Supplementary Fig. S2 ). Generally, the studies included a lack of clear description of randomization procedures and lack of clarity regarding drop-out rates. There are some studies that did not assess the fidelity of the interventions to determine if they were implemented as intended. Additionally, most of the studies had some concerns due to deviations from the intended interventions.

PRISMA flow chart of the search process of screened, included, and excluded articles

Characteristics of the included studies

Across the 27 studies, there were a total of 13,281 participants (49% female, 51% male) from 306 classes and 191 schools. The sample size ranged from 13 [ 51 ] to 4,234 participants [ 52 ] with the age of intervention children ranging from five to 12 years. Ten studies were conducted in North America (i.e., Canada and United States), seven in Europe (i.e., Finland, Germany, Ireland, Netherlands, Poland, and United Kingdom), eight in Australia, one in Asia (i.e., China), and one in South America (i.e., Brazil). Additionally, four studies were conducted in urban settings, one in rural and urban settings, one in a rural setting, and two in a suburban setting. The setting was not specified in 19 of the studies. The detailed characteristic of all of the included studies in Supplementary Appendix Fig. S1 .

Descriptions of CSPAP components

Study design.

Eight C-RCTs (30%), two RCTs (7%), and 17 N-RCT studies (63%) were included in this review.

Ten studies were C-RCTs or RCTs [ 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 ], with the average number of schools and classes across all studies being 14 (range 1–91) and 33 (range 2–157), respectively [ 57 , 58 ]. The average sample size was 369 students (range 28–1,736), [ 57 , 63 ] and the total number of students was 3,054 (48% Female, 52% Male). The average intervention duration, frequency, and length was 30 weeks (range 5–96) [ 58 , 59 ], two times per week, and 55 min per session (range 15–120) [ 54 , 63 ], respectively. For measurement of children’s MC, five studies of ten (50%) used Test for Gross Motor Development (TGMD-2nd Edition or -3rd Edition) [ 53 , 54 , 58 , 61 , 62 ], one study (10%) used Körper-koordinationtest Für Kinder (KTK) [ 55 ], two studies used other measurements (e.g., Dordel-Koch-Test [DKT]; 20%) [ 57 , 63 ], and two studies (11%) did not specify a measurement tool [ 59 , 60 ].

17 studies were N-RCTs (i.e., quasi-experimental), with the average number of schools and classes across all studies being four (range 1–9) [ 52 , 64 , 65 , 66 ] and six (range 2–20) [ 65 , 67 , 68 ], respectively. The average sample size was 564 students (range 13–1,460) [ 51 , 69 ], and the total number of students was 3,686 (49% Female, 51% Male). The average intervention duration, frequency, and length was 30 weeks (range 4–176) [ 70 , 71 ], two times per week (range 1–5) [ 51 , 52 , 67 , 72 ], and 59 min per session (range 25–120) [ 51 , 67 , 70 , 73 ], respectively. For measurement of children’s MC, 11 studies (64%) used TGMD-2 or -3 [ 64 , 65 , 67 , 68 , 69 , 72 , 73 , 74 , 75 , 76 , 77 ], four studies (24%) used KTK [ 51 , 65 , 66 , 71 ], two studies used other measurements (e.g., PE Metrics; 11%) [ 62 , 78 ], and one study (5%) did not specify a measurement tool [ 70 ]. Two studies used TGMD-2 and KTK [ 65 , 67 ].

Single CSPAP component interventions

Considering the CSPAP framework, nine studies out of 18 (50%) used only PE for the intervention [ 52 , 53 , 58 , 62 , 65 , 67 , 71 , 73 , 78 ], three studies (17%) used only PADS [ 57 , 70 , 75 ], four studies (22%) used only PABAS [ 60 , 64 , 72 , 76 ], and two studies (11%) used only FCE [ 55 , 63 ]. No study used only SI for the intervention.

For the studies that used only PE as the intervention approach, the average number of schools and classes across all studies were four (range 1–9) [ 52 , 58 , 65 ] and seven (range 2–20) [ 58 , 65 , 67 ], respectively. The average sample size was 691 students (range 42–4,234) [ 52 , 58 ], and the total number of students was 3,054 (50% Female, 50% Male). The average intervention duration, frequency, and length was 20 weeks (range 4–96) [ 52 , 71 ], two times per week, and 57 min per session (range 25–120) [ 67 , 73 ], respectively.

PE interventions involved PE lessons that incorporated revised FMS activities [ 73 ]; movement activities related to specific motor skills [ 53 ]; a PE curriculum that included motor skill themes and physical fitness activities [ 52 ]; goal-directed learning [ 71 , 78 ]; a movement program (Brain Gym) involving a series of simple-to-challenging FMS intended to enhance cognitive processing, psychomotor and whole-brain learning [ 58 ]; the Professional Learning for Understanding Games Education (PLUNGE) program, which aimed to increase the complexity of challenges experienced through gameplay-situated learning for the improvement of FMS [ 62 ]; and a gymnastics curriculum developed by Gymnastics Australia, which aimed to develop stability, locomotor and object control skills, and general body coordination [ 65 , 67 ]. The intervention deliverer varied across interventions. One study (11%) was delivered by a research team [ 58 ], seven studies (78%) by a school-based team (i.e., Trained PE teachers, classroom teachers and students) [ 52 , 53 , 65 , 67 , 71 , 73 , 78 ] and one study (11%) by a combined team (e.g., research team, school-based team, and parents) [ 62 ]. Additionally, four studies (44%) reported fidelity of intervention using observation and/or checklists [ 52 , 53 , 62 , 67 ].

For the studies that used PADS as the single intervention component [ 57 , 70 , 75 ], the average number of schools and classes across all studies being 35 (range 7–91) and 84 (range 11–157, respectively [ 57 , 75 ]. The average sample size was 826 students (range 336–1,736) [ 57 , 75 ], and the total number of students was 2,479 (55% Female, 45% Male). The average intervention duration, frequency, and length was 81 weeks (range 20–176) [ 57 , 62 , 70 , 75 ], two times per week, and 33 min per session (range 15–60) [ 57 , 75 ], respectively.

PADS interventions involved structured games to increase children’s FMS [ 75 ]; short daily classroom exercises [ 57 ]; and a whole-of-school health promotion approach aimed to develop children’s FMS by modifying the physical and social environment [ 70 ]. Two studies (75%) were delivered by a school-based team [ 70 , 75 ] and one study (25%) by a combined team [ 57 ]. None of the studies reported fidelity of intervention.

For studies that used only PABAS as an intervention approach, the average number of schools and classes across all studies was seven (range 1–16) [ 60 , 64 ] and three [ 76 ], respectively. The average sample size was 63 students (range 31–146) [ 60 , 64 ], and the total number of students was 252 (60% Female, 40% Male). The average intervention duration, frequency, and length was 13 weeks (range 8–26) [ 60 , 64 ], three times per week (range 2–5) [ 60 , 72 ], and 60 min per session, respectively.

The PABAS interventions involved outdoor low-organized games and indoor sports-based activities including swimming, floor hockey, and soccer as after school activities [ 72 ]; an after school program aiming to teach children the 12 basic motor skills from the TGMD-2 criteria [ 64 , 76 ]; and an after school club program that included multi-games activities, which focused on FMS development by using offering numerous opportunities for practice with learning cues [ 60 ]. Three studies (75%) were delivered by a research team [ 60 , 64 , 76 ] and one study (25%) by an after school-based team (i.e., after school program leaders) [ 72 ]. Two studies (50%) reported fidelity of intervention (using field observations) [ 64 , 76 ].

For studies that used FCE as the single intervention component, the average number of schools and classes across studies was one and two, respectively [ 55 , 63 ]. The average sample size was 193 students, and the total number of students was 385 (49% Female, 51% Male). The average intervention duration, frequency, and length was 27 weeks (range 6–48), two times per week, and 60 min per session, respectively [ 55 , 63 ].

The FCE interventions involved family involvement by providing tailored counseling [ 55 ], structured PA homework/materials, educating parents to an increase children’s MC, and goal-setting [ 55 , 63 ]. One study (50%) was delivered by a research team (i.e., coaches and research assistants) [ 55 ] and one study (50%) by a combined team (i.e., research team and parents) [ 63 ]. Both studies (100%) reported fidelity of intervention using observation and checklists.

Multiple CSPAP components interventions

A total of nine studies (33%) used intervention approaches that could be mapped onto multiple components within the CSPAP framework [ 51 , 54 , 59 , 61 , 66 , 68 , 69 , 74 , 77 ]. The most commonly used components in multicomponent approaches were PE ( n  = 8) followed by SI ( n  = 7) and PADS ( n  = 5). PABAS ( n  = 3) and FCE ( n  = 3) were included in less than half of the multicomponent studies. One multicomponent intervention did not include a PE component. No study included all five CSPAP components.

PE + 1 additional CSPAP component

Three of the studies (33%) reported an intervention that included PE + 1 additional CSPAP component. Two studies included SI and one study included PABAS. The average number of schools and classes across all studies were three (range 1–7) [ 59 , 61 ] and 21 (range 2–56) [ 59 , 68 ], respectively. The average sample size was 202 students (range 31–467) [ 59 , 68 ], and the total number of students was 605 (29% Female, 71% Male). The average intervention duration, frequency, and length was 50 weeks (range 6–96) [ 59 , 61 ], three times per week (range 1–4) [ 61 , 68 ], and 45 min per session (range 30–60) [ 59 , 61 ], respectively.

PE + 1 interventions involved the Professional Learning for Understanding Games Education (PLUNGE) program that aimed to improve children’s FMS in PE lessons through a professional learning process involving classroom teacher education and mentoring [ 61 ]; a Sports, Play, and Active Recreation for Kids (SPARK) based PE program designed to enhance children’s motor skills through a classroom teacher professional development program [ 61 ]; and PE lessons combined with an extracurricular after school program (From Fun To Sport) with an emphasis on the development of children’s FMS [ 68 ]. All three interventions were delivered by a school-based team (i.e., PE teachers and trained classroom teachers). Only one study (33%) reported fidelity of intervention using lesson observations [ 61 ].

PE + 2 additional CSPAP components

Three studies (33%) reported interventions that included PE + 2 additional CSPAP components. Two studies included the combination of SI and PADS with PE [ 69 , 77 ], and one study included SI and FCE with PE [ 66 ]. The average number of schools and classes across all studies was two and three, respectively. The average sample size was 664 students (range 174–1460) [ 69 , 77 ] and the total number of students was 1991 (50% Female, 50% Male). The average intervention duration, frequency, and length was 11 weeks (range 10–12), two times per week, and 50 min per session (range 30–60), respectively [ 66 , 69 , 77 ].

The PE + 2 interventions involved a CSPAP-based gross motor skill development program including the Dynamic PE for Elementary School Children curriculum during PE lessons, PA engagement opportunities throughout the school day during recess and regular classroom time (during which teachers integrated PA into academic lessons and classroom activity breaks via stretching, walking, jumping, or relaxation activities), and SI that provided teacher professional training to increase the quality of PE [ 69 ]; the Great Leaders Active StudentS (GLASS) program that included trained students who instructed their peers to improve FMS during PE lessons and classroom settings, and trained teachers supporting their peers’ instruction, which contributed an SI component to the program [ 77 ]; and physical exercise sessions during PE lessons (e.g., circuit training, aerobic/sports activities, and recreational games), parent support to promote PA during after school classes, and nutritional education sessions (e.g., goal setting and dietary counselling with parents) [ 66 ]. One study (25%) was delivered by a school-based team (i.e., PE teachers, classroom teachers, and students) [ 77 ] and two studies (75%) by a combined team (i.e., PE teachers, classroom teachers, medical or healthcare staff, parents, PA leaders, and the research team) [ 66 , 69 ]. Only one study (33%) reported fidelity of intervention using observations and a checklist [ 77 ].

PE + 3 additional CSPAP components

Two studies (22%) reported interventions that included PE + 3 additional CSPAP components. One study included the combination of SI, PADS, and FCE with PE and one study included SI, PADS, and PABAS with PE. The average number of schools and classes across all studies was seven and 25, respectively [ 54 , 74 ]. The average sample size was 667 students (range 357–976) and the total number of students was 1333 (44% Female, 56% Male) [ 54 , 74 ]. The average intervention duration, frequency, and length was 42 weeks (range 36–48), three times per week (range 1–5), and 98 min per session (range 75–120), respectively [ 54 , 74 ].

One PE + 3 intervention involved a CSPAP-based program that aimed to optimize the quality of PE. The intervention provided PA opportunities before and after school as well as during recess/lunch time, which created a number of opportunities for children to engage in free play or semi-structured PA by applying skills learned during PE lessons. Additionally, PA was integrated into academic lessons and classroom activities, and SI was addressed with continuous teacher training and assistance throughout the intervention [ 74 ]. The other PE + 3 intervention involved the implementation of six PA policies to support the promotion of PA and FMS competency within the PE lessons in combination with SI and PADS through teacher professional learning, student leadership workshops, and PA promotion tasks to achieve awards during recess and lunch. In addition, the intervention incorporated FCE via school–community connections (e.g., inviting local sporting organizations to assist with school sport programs) as well as a range of approaches targeting the home environment (e.g., newsletters, parent evening, and FMS homework) [ 54 ]. Both studies were delivered by a combined team (i.e., PE teachers, classroom teachers, principals, parents, PA leaders, and community leaders) and both reported the fidelity of the intervention using observations and a checklist [ 54 , 74 ].

Multicomponent interventions without PE

One study (11%) included the combination of PABAS and FCE with no PE component [ 51 ]. The total number of students was 13 (62% Female, 38% Male). The intervention duration, frequency, and length were ten weeks, one time per week, and 120 min per session, respectively [ 51 ]. The intervention program involved a community-based program with an additional home-based PA motor development program using goal-setting and parental motivation strategies [ 51 ]. The intervention was delivered by a combined team (i.e., researchers and parents) [ 51 ]. The study did not report fidelity of intervention.

Meta-analysis

Effectiveness across all interventions.

The meta-analysis for total 26 studies indicated a statistically significant and large pooled intervention effect on children’s total MC (Hedges’ g  = 0.71; 95% CI = 0.60–0.81; p  <.001; I 2  = 78.4%; Supplementary Fig. S3 ). The relative weight of each study in the analysis ranged from 1.40 to 6.22%. For all included studies, Egger’s regression test for asymmetry of the funnel plot was not significant (β = 0.32, p  =.17), indicating no evidence of publication bias (Supplementary Fig. S4 ). Results from the meta-regression found that intervention duration (β = -0.04; 95% CI = -0.29–0.19; p  =.69), delivery agent (β = -0.22; 95% CI = -0.65–0.21; p  =.31), and study design (β = 0.13; 95% CI = -0.10–0.36; p  =.28) were not found to be a statistically significant moderator variables/factors affecting overall study effect sizes (i.e., children’s total MC).

In a subsequent analysis, the studies adopting the TGMD − 2 or -3 tests were compared to studies including other types of assessments. The latter analysis was conducted as a proxy for effects of types of MC measurements. 17 studies measured children’s MC using the TGMD-2 or -3 tool. The meta-analysis for studies indicated a statistically significant and large pooled intervention effect on children’s total MC (Hedges’ g  = 0.79; 95% CI = 0.63–0.95; p  <.001; I 2  = 38.2%; Supplementary Fig. S5 ). The relative weight of each study in the analysis ranged from 3.88 to 9.30%. Additionally, 11 studies measured children’s MC using other measurement tools (e.g., KTK, PE Metrics, and DKT). The meta-analysis for these studies indicated a statistically significant and moderate pooled intervention effect on children’s total MC (Hedges’ g  = 0.57; 95% CI = 0.42–0.72; p  <.001; I 2  = 64.1%; Supplementary Fig. S6 ). The relative weight of each study in the analysis ranged from 3.77 to 12.62%. Specifically, five studies measured children’s MC using KTK tool. The meta-analysis for studies indicated a statistically significant and moderate pooled intervention effect on children’s total MC (Hedges’ g  = 0.41; 95% CI = 0.28–0.57; p  <.001; I 2  = 86.7%; Supplementary Fig. S7 ). The relative weight of each study in the analysis ranged from 4.04 to 12.82%.

Effectiveness of PE only vs. other single component interventions

Nine studies used only PE as the intervention approach. The meta-analysis for these studies indicated a statistically significant and large pooled intervention effect on children’s total MC (Hedges’ g  = 0.79; 95% CI = 0.55–1.04; p  <.001; I 2  = 66.7%; Supplementary Fig. S8 ). The relative weight of each study in the analysis ranged from 7.40 to 13.30%. Eight other studies used non-PE single component intervention approaches (i.e., PADS + PABAS + FCE). The meta-analysis for these studies indicated a statistically significant and moderate pooled intervention effect on children’s total MC (Hedges’ g  = 0.48; 95% CI = 0.29–0.68; p  <.001; I 2  = 85.0%; Supplementary Fig. S9 ). The relative weight of each study in the analysis ranged from 10.81 to 24.62%.

In a subsequent analysis, the studies that used non-PE single component interventions were analyzed. Specifically, three studies used only PADS as the intervention approach. The meta-analysis for these studies indicated a statistically significant and moderate pooled intervention effect on children’s total MC (Hedges’ g  = 0.48; 95% CI = 0.27–0.69; p  <.001; I 2  = 76.5%; Supplementary Fig. S10 ). The relative weight of each study in the analysis ranged from 14.20 to 45.38%. Additionally, three studies used only PABAS as the intervention approach. The meta-analysis for these studies indicated a statistically significant and moderate pooled intervention effect on children’s total MC (Hedges’ g  = 0.50; 95% CI = 0.13–0.89; p  <.05; I 2  = 0.0%; Supplementary Fig. S11 ). The relative weight of each study in the analysis ranged from 25.28 to 46.18%.

Effectiveness of interventions addressing multiple CSPAP components

Three studies reported intervention approaches that used PE and one additional CSPAP component (PE + 1) to increase children’s MC. The meta-analysis for these studies indicated a statistically significant and moderate pooled intervention effect on children’s total MC (Hedges’ g = 0.64; 95% CI = 0.33–0.95; p  <.001; I 2  = 48.2%; Supplementary Fig. S12 ). The relative weight of each study in the analysis ranged from 13.25 to 18.30%. Additionally, three studies reported intervention approaches that used PE and two additional CSPAP components (PE + 2) to increase children’s MC. The meta-analysis for these studies indicated a statistically significant and moderate pooled intervention effect on children’s total MC (Hedges’ g  = 0.55; 95% CI = 0.27–0.82; p  <.001; I 2  = 52.9%; Supplementary Fig. S13 ). The relative weight of each study in the analysis ranged from 12.98 to 32.75%.

The purpose of this systematic review and meta-analysis was to use the CSPAP framework to synthesize the evidence of the effectiveness of PA interventions in increasing MC as a primary outcome of children aged 5–12. Twenty-seven studies met the inclusion criteria and were included in the qualitative analysis and twenty-six studies were included in the quantitative analysis. The results of the aggregate meta-analysis indicate that effect sizes for the development of MC from pre-post intervention ranged from moderate to large. In light of our results, a wide range of CSPAP-aligned PA intervention approaches appear to be promising avenues in enhancing children’s MC. However, there is considerable variation in study design, sample size, delivery agent, and study context, and studies were implemented in over 11 countries across diverse settings. Additionally, the results do not show clear evidence that increased PA duration or frequency (i.e., dose) has a detrimental effect on the development of children’s MC, which aligns with McDonough et al. [ 79 ].

Results of this review indicated that the majority of studies included PE as a component of either a single (33%) or multicomponent (30%) approach and showed beneficial effects on the development of children’s MC. Specifically, PE commonly included the integration of movement activities with cognitively challenging PA learning experiences related to FMS and implementation of an established curriculum (e.g., SPARK) with professional teacher training [ 52 , 59 , 61 ]. Especially in PA interventions that employ complex, challenging learning tasks, how such activities are delivered and implemented may crucially affect learning outcomes [ 80 ]. Jiménez-Díaz et al. [ 81 ] in a review of 36 articles, present that naturally occurring PE classes were less effective at increasing children’s MC than a research specialist-led motor intervention, based on PE teachers’ lack of expertise for designing and implementing developmentally appropriate movement activities. However, our results showed that school-based teams (i.e. PE teachers and classroom teachers) can play a crucial role in increasing children’s MC with professional training and structured curriculum. Likewise, ongoing teacher training and support appears to be a key element of effective PE curriculums and successful interventions by enhancing the unique features of qualitative enrichment [ 82 , 83 , 84 ].

The PE-based programs often evaluated outcomes related to PA, fitness, and body composition [ 85 ]. Conversely, most of the included studies focused on the development of MC beyond PA opportunities. These results are consistent with those of a previous systematic review, which found that FMS-based intervention programs appeared to have larger effects than interventions focused strictly on increasing PA [ 86 ]. Further, when it comes to curriculum, research has demonstrated and noted the importance of structure when promoting children’s motor skill development [ 20 , 87 ]. In this review, a number of the PE components within the CSPAP framework assessed an enhanced PE curriculum with a focus on optimal MC development as compared to traditional PE or free play [ 53 , 62 ], some simply tested the benefit of an additional time allotment of PE [ 68 ], and some compared both modified PE and time spent in PE lessons [ 71 , 78 ]. Overall, implementing a purposefully designed intervention approach with PE lessons had a positive effect on the development of MC. Further, of those studies that compared PE intervention programs versus typical PE [ 70 ], results support the importance of the quality of instructional approaches that enable students to have developmentally appropriate tasks/activities with learning cues, multiple opportunities for individual practices in a mastery climate, and individualized feedback [ 88 , 89 , 90 , 91 ]. These results were quite similar to those demonstrated by Morgan et al. [ 92 ], who highlighted the benefits of using a pedagogical approach to develop children’s FMS in PE.

In this review, we considered dose (i.e., as the amount of time/duration devoted to motor skill instruction and practice) [ 93 ], specifically < 6 months vs. ≥ 6months, as a possible moderating factor in the effectiveness of PA interventions on MC development in children. Based on the results, however, the intervention dosage needed to obtain MC proficiency is unclear. For instance, some studies report significant improvements in children’s MC after a 550 min dose over 13 weeks [ 53 ], 1,400 min dose over 8 weeks [ 64 ], 1,400 min dose over 12 months [ 66 ], and 2400 min dose over 20 weeks [ 75 ], whereas other studies fail to see significant effects after a 480 [ 58 ] or 3600-min dose [ 55 ] at five weeks and 12 months, respectively. Similarly, previous literature demonstrates inconsistencies regarding the amount of intervention needed to produce positive developmental changes in MC. Wick et al. [ 94 ], found interventions conducted from one to five-months had a larger effect on FMS than interventions lasting over six months. In addition, a recent meta-analysis study indicated that children aged 3–5 need to practice their FMS with a teacher-led intervention regularly (i.e., 3 times per week for ≤ 6 months) to achieve significant improvement in MC [ 95 ]. Specifically, Van Capelle et al. [ 96 ], suggested that interventions for increasing FMS must be implemented more than three times per week and that sessions should last longer than 30 min. However, the meta-analysis by Logan et al. [ 20 ], reported a nonsignificant relationship between effect sizes of FMS improvements and intervention duration with a dosage between 500 and 1,400 min. A possible explanation for the results is that there was heterogeneity in study length (4 to 192 weeks), frequency of program delivery (1 to 5 times per week), and duration of program sessions (15 to 120 min) across the included studies. Another possible explanation is that there may have been a “ceiling effect” in which children had already achieved better performance in the early stages of the intervention. As a result, more time (quantitative aspect) may not necessarily translate to better performance (quality aspect). Robinson et al. [ 93 ], presented that as little as 600 min of high-quality instruction during the intervention program can significantly improve children’s MC. Thus, future research is warranted. It would be beneficial to examine the impact that different intervention dosages (e.g., duration and frequency) would have on children’s MC development under similar PA intervention conditions. Additionally, most studies did not report the dose received (i.e., on-task time in the tasks/activities), which is an important area for future research because motor skill development theory shows that one of the key factors is the number of correct practice trials a child completes [ 97 ]. Ultimately, understanding patterns of change resulting from different ranges of intervention dosages could illustrate how only minimal amounts of time could lead to positive developmental changes in MC and help establish recommendations and policies for practitioners implementing CSPAPs.

Interestingly, studies involving multiple component interventions mainly addressed the FCE and SI CSPAP components [ 51 , 54 , 59 , 61 , 66 , 69 , 74 , 77 ]. The multicomponent interventions were collaboratively delivered by a variety of facilitators, such as PE teachers, classroom teachers, administrators, coaches, community leaders, parents, and medical or healthcare staff. The results of this review parallel previous interventions that involved parents as promoters for PA and MC in their own children [ 98 , 99 ]. Overall, it seems reasonable to assert that the FCE and SI components of the CSPAP framework function as important elements in the support system for PA program implementation in schools [ 26 ], and can help to enhance children’s MC. However, there is insufficient evidence specific to each component (FCE or SI) to make conclusions about the its specific contribution to MC, and further research is needed to determine which strategies are most effective for optimizing FCE and SI to support the development of MC in children.

Overall, there has been a lack of variety in theories used to guide intervention development. The studies in this review used the socio-ecological model [ 54 , 66 ], motivation theory [ 51 , 78 ], and social cognitive theory [ 55 ]. However, other theoretical perspectives should be considered, as well. For example, interventions could incorporate strategies such as encouraging teachers to provide positive feedback and emphasizing mastery of skills rather than competition. These practical strategies reflect constructs related to motivation theories such as Self-Determination Theory [ 100 ] and Achievement Goal Theory [ 101 ]. Moreover, there is a lack of strong process evaluation across studies. While intervention programs demonstrated improvements in children’s MC, multiple components were typically implemented simultaneously. Nearly half of the studies did not measure intervention implementation elements (e.g., fidelity and selection of participants). Additionally, some studies did not describe their instructional strategies in detail. As such, it is unclear how these variables affected study findings. It is important to show the study context and resources to improve the interpretation of research findings.

The meta-analysis results indicated that the pooled effect sizes of all interventions to increase children’s overall MC were statistically significant, with 11 studies (42%) reporting large effect sizes. However, there was a small number of heterogeneous studies included in the meta-analysis. Subsequently, a subgroup comparison between measurements was performed. Studies were separated by measurement tool (i.e., TGMD-2 or-3 vs. other measurements); the studies that used TGMD-2 or -3 had a large effect on MC [ 64 , 75 , 76 ], whereas other assessments had a moderate effect on MC (Hedges’ g  = 0.79 vs. 0.57). Thus, not all PA intervention programs have the same effect on the development of MC. For example, Rudd et al. [ 65 , 67 ], which assessed changes in both TGMD-2 and KTK, reported different effect sizes (Hedges’ g  = 0.79 vs. 0.41) in the development of MC in their gymnastics intervention group. Since studies using TGMD-2 or -3 often show large effect sizes, they could thus be an effective way to assess the development of children’s MC (as opposed to other measurements). Although these measurements are commonly used for assessing children’s MC, the variety in scoring criteria protocol might provide different aspects of MC across the different movement dimensions evaluated [ 20 , 67 ]. Research has also shown that there is a low-to-moderate correlation between TGMD-2 and KTK in children [ 102 ]. Therefore, further studies on the effect of PA interventions on MC should carefully consider the types of assessments (i.e., process measure or outcome of product) and their associations with intervention outcomes.

The current meta-analysis found that single PE component interventions had a larger effect on MC than other single-component approaches. A common misconception is that MC development is a naturally occurring phenomenon; however, literature suggests that it must “be practiced, taught, and reinforced through developmentally appropriate movement programs” [ 87 ]. A large number of previous studies using the CSPAP framework focus mainly on the potential of PE to provide enough amounts of PA, that is, its contribution to the achievement of daily PA recommendations [ 26 ]. The main results of the meta-analysis showed that the PE component is foundational to learning and developing MC in children [ 26 , 103 ]. Previous research found that PE contributed to improving elementary school students’ manipulative skills [ 52 ] and motor skill competence [ 103 ]. In a meta-analysis study, Dudley et al. [ 104 ], also presented that PE can be efficacious in improving MC in primary school children. Moreover, the quality of instruction and time spent in practice are of utmost importance in improving MC [ 16 ]. However, limited research is devoted to studying the unique potential of PE within the CSPAP framework to develop MC in schoolchildren aged 5–12 and its impact on long-term PA trajectories [ 7 ]. Additionally, our results suggest that given the limited PE curriculum time in elementary schools, strategies to engage classroom teachers and/or parents in both school-based lessons and to support practice opportunities outside of PE class and school may be a worthwhile target for future interventions. That is, implementing a PA program using other single components in the CSPAP framework has the potential to support PE’s goal of developing children’s MC.

There was minimal effectiveness of adding other CSPAP components to PE for the development of children’s MC. Many of the interventions included in the current review were multicomponent interventions. We expected that multiple components being used to increase MC may be a more effective approach than the single PE component approach. Unfortunately, the results suggest multicomponent interventions (adding other components to PE) have had minimal impact on the development of children’s MC as indicated by the effect size values. A possible explanation for our results is that the quality of PA programs might be more important than the quantity of CSPAP components used to increase children’s MC. More research, therefore, is warranted to examine how the quality of PA experiences provided through each CSPAP component can impact the MC of school-age children.

In this review, moderation analyses were performed to explore the effectiveness of potential moderators (study length, delivery agent, and study design) on the effect size of MC with meta-regression [ 40 ]. In general, our findings suggest that the effects of potential moderator variables had no significance on children’s MC. In line with the present results, Loras [ 31 ] also showed that participants’ ages, the total amount of time for intervention, and the type of MC measurement were not statistically significant moderators of effect size. However, a handful of studies had insignificant heterogeneity, indicating substantial differences in study contexts and characteristics. Additionally, there was limited information available for some moderator variable analyses. Thus, further studies should collect and report more complete data so that potential moderators can be examined to help us better understand the effects of potential moderator variables on the development of MC.

Strengths and limitations

To the best of our knowledge, this is the first review to examine PA intervention effects on the MC of children aged 5–12 years from a CSPAP perspective. Although previous meta-analyses on this topic have been conducted, they were limited to FMS in the early childhood age band [ 37 , 94 , 95 , 96 ]. In this review, we included elementary school age and, not only FMS, but also motor coordination and motor proficiency, representing a broader range of MC outcomes. Additionally, our review provided insight into different intervention approaches to change children’s MC within the context of the CSPAP framework, highlighting the quality of PE as a particularly effective foundational component. Another strength of this review was that we used a sensitive search strategy to ensure relevant studies were not missed. In addition, a rigorous review methodology, including independent, duplicate reviews of selected studies, ensured most studies were captured [ 40 ].

This study also has several limitations. First, for practical reasons, we only included peer-reviewed studies published in English; non-English publications, and therefore further comparative evidence, may have been available on the topic. Second, there was noticeable heterogeneity of study approaches and assessment tools used to test children’s MC across studies, which makes it difficult to compare findings across the studies. Nevertheless, validated testing instruments were utilized across included studies which minimized a major domain of bias and further strengthened the overall evidence of this review. Third, the review included small sample sizes and some articles were feasibility studies or pilot trials. Finally, this review potentially excludes studies published after November 2021.

The current review provides a unique contribution to the literature through its primary focus on considering the effectiveness of PA interventions on children’s MC from a CSPAP perspective. In light of our results, single and/or multi component intervention approaches within the CSPAP framework appear to be a promising avenue to promote MC in school-aged children (5–12 years old). This review also highlights that CSPAP-aligned PA programs should be tailored to the context within which they are delivered, most notably the PE component which can be best adapted to the context through professional teacher training. Also, combining different PA intervention strategies (e.g., goal setting and reinforcement) with the SI/FCE components should be considered to improve MC through increased engagement and motivation.

Beyond these findings, this study identified avenues for future research. To increase intervention engagement and efficacy, future studies should examine the impact of a greater emphasis on children’s MC. It is important to improve our understanding of which CSPAP-aligned PA intervention approaches are more effective than others by stratifying for the target groups, the setting, and the characteristics of the interventions. In other words, we need to identify and investigate well-designed interventions, including tailored types of PA programs. Additionally, future research should use stronger methodological approaches and consider expanding the theoretical ground for this research. Specifically, in order to make intervention studies more robust, research using high-standard randomization procedures to investigate the ability of CSPAPs to improve children’s MC is needed. Ultimately, we should pursue how to effectively translate the evidence into practice to better conceptualize CSPAPs designed for children’s MC development.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Comprehensive School Physical Activity Program

Family and Community Engagement

Fundamental Motor Skills

Motor Competence

Physical Activity Before and After School

Physical Activity During School

Physical Activity

Physical Education

Randomized Controlled Trial

World Health Organization

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Jongho Moon

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JM made contributions to the conception and design, literature search, study selection, data extraction, risk of bias assessment, data analysis, and drafting of the manuscript; CAW contributed to the conception, design of the study, risk of bias assessment, data interpretation, and revision of the manuscript for critically important intellectual content; DFS, AB, and KLM made substantial contributions to the conception and design of the study, and revision of the manuscript; MB contributed to risk of bias assessment, data analysis, and interpretation of results; CAE, CBM, LM, and LR contributed to literature search, study selection, and data extraction. All authors have read and approved the final version of the manuscript and agree with the order of the presentation of the authors.

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Supplementary Material File: (a) outlines the detailed search strategy and specific key terms employed to identify relevant studies focusing on outcomes related to motor skill competence in children; (b) contains figures S1-S13, offering visual representations of quality assessments, effect sizes, and publication bias assessments related to the included studies; and (c) includes a table that shows the characteristics of the included studies, specifying the population, study design, intervention focus, measurement tools, fidelity reporting, and main findings.

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Moon, J., Webster, C.A., Stodden, D.F. et al. Systematic review and meta-analysis of physical activity interventions to increase elementary children’s motor competence: a comprehensive school physical activity program perspective. BMC Public Health 24 , 826 (2024). https://doi.org/10.1186/s12889-024-18145-1

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Mental health interventions for individuals with serious mental illness in the criminal legal system: a systematic review

• Maji Hailemariam 1 ,
• Tatiana E. Bustos 2 ,
• Barrett Wallace Montgomery 2 ,
• Garrett Brown 1 ,
• Gashaye Tefera 3 ,
• Rosemary Adaji 4 ,
• Brandon Taylor 1 ,
• Hiywote Eshetu 1 ,
• Clara Barajas 5 ,
• Rolando Barajas 6 ,
• Vanessa Najjar 7 ,
• Donovan Dennis 8 ,
• Jasmiyne Hudson 8 ,
• Julia W. Felton 9 &
• Jennifer E. Johnson 1  

BMC Psychiatry volume  24 , Article number:  199 ( 2024 ) Cite this article

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Globally, individuals with mental illness get in contact with the law at a greater rate than the general population. The goal of this review was to identify and describe: (1) effectiveness of mental health interventions for individuals with serious mental illness (SMI) who have criminal legal involvement; (2) additional outcomes targeted by these interventions; (3) settings/contexts where interventions were delivered; and (4) barriers and facilitating factors for implementing these interventions.

A systematic review was conducted to summarize the mental health treatment literature for individuals with serious mental illness with criminal legal involvement (i.e., bipolar disorder, schizophrenia, major depressive disorder). Searches were conducted using PsychINFO, Embase, ProQuest, PubMed, and Web of Science. Articles were eligible if they were intervention studies among criminal legal involved populations with a mental health primary outcome and provided description of the intervention.

A total of 13 eligible studies were identified. Tested interventions were categorized as cognitive/behavioral, community-based, interpersonal (IPT), psychoeducational, or court-based. Studies that used IPT-based interventions reported clinically significant improvements in mental health symptoms and were also feasible and acceptable. Other interventions demonstrated positive trends favoring the mental health outcomes but did not show statistically and clinically significant changes. All studies reported treatment outcomes, with only 8 studies reporting both treatment and implementation outcomes.

Our findings highlight a need for more mental health research in this population. Studies with randomized design, larger sample size and studies that utilize non-clinicians are needed.

Peer Review reports

Globally, individuals with mental illness get involved with the criminal legal system at a greater rate than the general population [ 1 , 2 ]. For example, there are more people with mental illness currently in the U.S. criminal legal system than those receiving care in inpatient psychiatric hospitals [ 3 ]. Individuals with mental illness have an elevated risk of criminal legal involvement including interacting with 911 calls, local law enforcement, pretrial jail detention, court appearances, specialty courts, jail sentences, probation, and parole [ 2 , 4 ]. Once involved in the criminal legal system, individuals with mental illness are also more likely than those without mental illness to have multiple incarcerations, serve longer sentences, be denied probation or parole supervision, have their probation or parole revoked for technical violation, and return to jail in the first year after release [ 5 , 6 , 7 ].

Given the large degree of overlap of criminal legal involvement of individuals with mental illness, the criminal legal system serves as a de facto public health system in most high-income countries [ 8 ]. On the contrary, mental health care needs of criminal legal involved individuals in low-and middle-income countries (LMICs) are often neglected and underfunded [ 9 ]. Criminal legal settings in LMICs also experience a higher burden of mental health and substance use disorders compared to high-income countries [ 10 , 11 ]. Moreover, globally, criminal legal settings are complex systems that face significant barriers to implementing programs and interventions due to limited institutional capacity and resources, lack of qualified workforce, restrictive policies, lack of programmatic support, and navigating varied treatment preferences and staff attitudes [ 12 ]. These inherent institutional barriers create more complexities to the undertaking of delivering mental health interventions in the criminal legal system [ 13 ].

Evidence from most high-income countries indicate that many individuals with mental illness who report criminal legal involvement unfortunately have their first contact with a mental health service provider while in a correctional facility [ 14 , 15 , 16 ]. Many correctional facilities also have distinct mental health units [ 17 ]. However, a significant proportion of individuals with criminal legal involvement, particularly those in LMICs, still face barriers to accessing mental health care both during incarceration and in the community [ 18 ]. Correctional facilities often struggle to meet the treatment needs of individuals with mental illness in their custody [ 12 , 19 ].

In recent years, there has been interest in integrating mental health interventions with community reentry efforts to improve health and criminal legal outcomes [ 20 , 21 , 22 ]. This effort also includes diversion programs, alternatives to incarceration, and better community-based mental health crisis services to keep people with serious mental illness out of jail [ 22 ]. For individuals with serious mental illness leaving jails and prisons, successful community reentry involves prompt linkage to community mental health, medical care and substance use services. Community-based alternatives to incarceration including jail diversion, mental health courts, reentry programs, crisis interventions and other programs have been introduced to improve the mental health and criminal legal outcomes of individuals with mental health needs [ 21 ].

Community-based and correctional or healthcare facility-based interventions have been introduced to address the needs of individuals with mental health challenges in the criminal legal system [ 9 , 23 ]. For example, courts started requiring routine mental health screening and treatment for populations with criminal legal involvement [ 24 ]. Various evidence-based interventions are being implemented with the aim of reducing the number of individuals with mental illness in correctional facilities [ 21 ].

The Sequential Intercept Model (SIM) helps to understand the various points at which individuals with SMI come into contact with the criminal legal system. The model provides six criminal legal intercepts ranging from communities to community corrections where interventions are possible to implement to prevent involvement with the criminal legal system.

Along these intercepts, jail diversion programs, mental health courts, critical time intervention and other programs have been designed to improve criminal legal involvement and public health outcomes for individuals with mental health needs who have criminal legal involvement. However, several barriers to implementation of evidence-based interventions with criminal legal-involved populations persist [ 25 ]. Moreover, prior systematic reviews have focused on program impacts on substance use and return to prison outcomes, demonstrating limited evidence synthesizing the extent of improvements made primarily on individual mental health outcomes.

This systematic review summarizes the mental health treatment literature for individuals with serious mental illness who have criminal legal involvement. We define serious mental illness (SMI) as psychotic and affective disorders associated with long-term and persistent disability and substantial functional impairment. These include schizophrenia, bipolar disorder or major depressive disorder. We define the mental health treatment literature for individuals with SMI as the peer reviewed scientific literature on the mental health interventions in this population, in which measures of mental health are the primary outcome. Given the emphasis in other systematic reviews, the current project builds the evidence base on how mental health interventions affect individual mental health outcomes among individuals with serious mental illness who have criminal legal involvement. Specifically, the review aimed to identify and describe: (1) mental health interventions for individuals with SMI who have criminal legal involvement; (2) the mental health outcomes used, (3) additional outcomes targeted by these interventions; (4) settings/contexts where interventions were delivered; and (5) barriers and facilitating factors for implementing the interventions using the Consolidated Framework for Implementation Research (CFIR). The CFIR is a conceptual framework that helps to map out implementation contexts and identify potential determinants for the implementation and effectiveness of an intervention. The framework has five domains including intervention characteristics, outer setting, inner setting, characteristics of individuals, and process of implementation.

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline to structure this review. Methods of data collection and analysis were documented a priori . This systematic review protocol was registered in the PROSPERO registration system on 06/07/2020 under registration number CRD42020172627. An update to the information provided in PROSPERO was done to reflect changes in the study.

Eligibility criteria

Eligible studies included articles that (1) were peer reviewed; (2) were written in English; (3) examined a specific intervention among individuals with SMI who have criminal legal involvement; (4) had mental health as a primary outcome; and (5) provided a description of the intervention used. Articles were excluded if they (1) were a review of or secondary analysis of the work of others; (2) lacked original data relating to intervention outcomes; or (3) were not peer reviewed. We did not exclude studies based on study design.

Information sources

We searched electronic databases to identify potentially eligible studies. These include PsychINFO (1887–2020), PubMed (1946–2020), Embase (1976–2020), Web of science (1900–2020), ProQuest: ERIC and CSA Social Services Abstract, and Medline (PubMed) (1806–2020). There were no restrictions to time in order to find the most comprehensive set of articles focused on mental health interventions among criminal involved populations with SMI. Additional articles were identified by reviewing reference lists of eligible papers. We conducted an initial search in June 2020, and additional time-restricted searches (June 2020 – June 2022) were run to identify more recently published studies.

Search strategy

We used different combinations of pre-identified keywords. All search terms were identified from a preliminary overview of literature focused on mental health interventions in criminal legal settings. The keywords used included: “evidence-based,” “mental health,” ”EBIs,””interventions,” “mental illness,” “justice-involved,” “jail,” “prison,” “services,” “inmates,” “serious mental illness,” “depression,” “schizophrenia”, “bipolar disorder”, “prisoners,” “behavioral health,” “probation,” “court diversion,” “criminal,” “diversion,” and “parole”. We combined these terms using “AND” or “OR”. If available, searches utilized a filter to only identify “peer-reviewed” articles written in the English language. Otherwise, we filtered out articles in other languages and papers that did not go through a peer-review process manually. Duplicate articles were removed once all articles from these initial searches were identified and stored in a file.

Study selection

Three of the authors (TB, BWM, MH) reviewed the title and abstracts of 5,778 articles, including the initial 3,429 articles as well as 1,509 articles identified from the updated review conducted in 2021–2022 using exported Excel sheets collated with all articles. Articles were eligible for a full-text review if they met the inclusion criteria described above. Whenever the reviewers could not determine eligibility based on these details in the abstract and the title, the articles moved on to the full-text review phase by default. If the title/abstract was not relevant, then the article was excluded from the review. Any disagreements between reviewers were resolved using consensus procedures. The first and/or second author assisted team members on disagreements that could not be resolved. During this phase, 5,392 articles were excluded. After the title/abstract review phase, eight additional members were added to the coding team to begin reviewing 386 articles in the full-text review phase using Qualtrics as a data management platform. Five pairs of reviewers independently reviewed and coded 20–30 articles (of the 386) that were randomly assigned to them using a random number generator. Reviewers read the full articles more in depth and applied the eligibility criteria described above to determine whether articles should be included in the review. Disagreements at this phase were resolved using consensus procedures where the pair of reviewers met and discussed their agreements and disagreements regarding an article. Wherever reviewers could not resolve the differences after a consensus meeting, a third independent reviewer was invited (e.g., first or second author). During this phase, 273 articles were excluded. The same procedures were followed for the secondary full-text review of 113 potentially eligible articles, where reviewers began coding characteristics of the studies for data extraction. At this phase, 100 articles were excluded for a variety of reasons that are specified in Fig.  1 . Once this phase was completed, the review resulted in 13 articles (see Fig.  1 : Study Flow Chart) that were found to be eligible for the final data extraction and reporting phase of the study.

Flow chart of the study

Data collection process

Our team included 10 reviewers with varying levels of mental health research training (i.e., from bachelors to PhD). Reviewers attended and completed multiple trainings focused on systematic review procedures to assure quality of reviews. Grounded on the first and second author’s prior training and best practices from a prior systematic review publication, the training included an overview of the PRISMA guidelines, an introduction to mental health needs of criminal legal involved populations, a review of the systematic review protocol, an orientation of the data extraction form using a practice article, and ongoing team discussions on the coding framework. To facilitate data management, extraction and synthesis, a framework was developed based on the objectives listed in the systematic review protocol. A Qualtrics survey was created based on the framework and was used during the initial and secondary full-test review phase as well as the data extraction. The survey was pilot-tested by a team of 10 reviewers who completed the survey after reviewing the first five articles assigned to them. Feedback from the pilot-review stage was used to enhance the clarity and content of the survey questions. Another practice article was then assigned to assess the consistency of codes and to clarify any misunderstanding of operational definitions. The study team met over Zoom to review responses to the practice article and discuss experiences with the coding process to ensure intercoder agreement for consistency across reviewers. Once procedures were clear and consistent, each reviewer was assigned 20–30 articles to code independently. Weekly team meetings were held throughout the Fall 2020 and Summer 2022 to discuss any issues or concerns regarding the coding process. Pairs of raters then met individually to discuss discrepancies in codes until a consensus was reached. We have achieved 100% concordance between the raters. All articles were independently double-coded.

Data extracted for each article included 30 items detailing: (1) reviewer and article information (e.g., publication date, author); (2) intervention details; (3) study design and methods; (4) treatment and/or implementation outcomes; (5) demographics of participants; (6) facilitators and barriers to implementation as conceptualized in the Consolidated Framework for Implementation Research (CFIR); and (7) other comments or concerns regarding the article. Specific items used for the data extraction phase are available in the systematic review protocol (available upon request).

Risk of bias

We used broad inclusion criteria in order to minimize the risk of publication bias [ 26 ]. Thus, studies were included regardless of their outcomes (negative or positive) or research design (i.e., randomized vs. open trials). Appraisal tools from the Equator Network were utilized based on the study designs to enhance quality of reviews [ 27 ]. To determine the risk of bias in the design, conduct and reporting of randomized trials, we used the CONSORT checklist, an evidence-based recommendation for reporting randomized trials [ 28 ]. To assess the risk of bias in observational studies, we used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist [ 29 ]. The 32 item Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to determine the risk of bias in qualitative studies (i.e., of implementation barriers and facilitators) [ 30 ].

Data analysis

We used a Qualtrics survey to capture reviewer assessments during the initial and secondary full text reviews and to code eligible articles for data extraction and reporting. A Qualtrics survey was created using our systematic review protocol. The survey was comprised of questions in the areas of names of authors, year of publication, description of the intervention, the study population, the setting, the interventionists, the outcomes reported etc. All reviewers received a link to the Qualtrics survey via email. All articles were assigned to five pairs of reviewers for double coding. Each reviewer completed the Qualtrics survey independently after reading the articles assigned to them, following the data extraction protocol. Once independent reviews were submitted, the second author reviewed the Qualtrics data to identify discrepancies and then notify reviewers to schedule virtual consensus meetings. Once notified via email, pairs of reviewers met to discuss discrepancies in their coding for intercoder agreement. Of note, verbal consensus procedures between coders, such as those detailed in the current review, is considered a best practice approach for improving trustworthiness of qualitative coding [ 31 ]. Once consensus was reached for all studies in the full-text review phase, a separate Qualtrics link was used to document the final coding decisions. Data from Qualtrics was exported to SPSS and Microsoft Excel for descriptive analyses of final codes (e.g., frequencies). The review team met to discuss emerging themes and to create a reporting structure based on the objectives of the study. Recurrent themes that were identified were thematically categorized to facilitate reporting.

A total of 13 eligible articles were included, ranging from publication dates of 1997 to 2020. Designs of the eligible studies included randomized controlled trials (RCTs; n  = 6), quasi-experimental ( n  = 4), and open-trial ( n  = 3). The types of analysis included were quantitative ( n  = 12) and mixed methods ( n  = 1). Per the World Bank classification of countries [ 32 ], all of the eligible studies were from high-income countries. Based on the appropriate appraisal tools from the Equator Network (STROBE for observational studies and CONSORT for RCTs), the quality of the studies were ranked good and above.

Outcomes reported

All of the studies ( n  = 13) included mental health as their primary outcome (see Table  1 ). Reduction of symptoms of serious mental illness was reported by the majority of the studies 85% ( n  = 11 studies). Six (46%) of the 13 studies reported both mental health treatment outcomes (reduction in symptoms, improvement in functioning etc.) and implementation outcomes including sustainment of gains (meaning continued delivery of the program or longer-term maintenance of treatment outcomes), feasibility and acceptability, and/or cost-effectiveness. One study reported health services outcomes related to reduction in caseloads, improvement in referrals and triage assessments [ 33 ]. Table  1 , below presents the reported outcomes in each of the included 13 studies.

Level of evidence

We ranked the strength of evidence based on the strength of evidence pyramid [ 34 ]. Accordingly, RCTs were assigned level I, cohort studies or quasi-experimental studies with a comparison group as level II, and open trials and quasi-experimental design with no comparison group were ranked as level III. Table  2 presents the level of evidence and the sample sizes of the 13 studies. A description of changes in mental health outcomes in the 13 studies are also presented in Table  2 ; significant outcomes are noted when appropriate.

We also reviewed the implementation outcomes reported across studies in the domains of efficacy, feasibility and acceptability, program effectiveness, cost-effectiveness and maintaining intervention gains. All studies that included implementation outcomes ( n  = 6) focused primarily on the feasibility and acceptability of interventions [ 33 , 35 , 36 , 37 , 38 , 39 ]. One study focused on the cost-effectiveness of the implementation of interpersonal psychotherapy for major depressive disorder in a prison population [ 40 ].

The interventionists

Table  2 includes the types of interventionists used in each study. All except three interventions were delivered by mental health clinicians ( n  = 10). Some of the studies reported intervention that were delivered by clinicians in collaboration with case managers [ 41 ], correctional staff [ 33 ] and art therapists [ 42 ]. Only three studies [ 35 , 43 , 44 ] did not involve mental health clinicians.

The intervention setting

Table  2 also includes the types of settings each intervention took place. Ten of the 13 studies reported that the interventions were delivered inside a correctional facility (jail or prison). The other three studies used interventions delivered in the community setting [ 41 , 43 , 44 ].

The interventions and intervention characteristics

There was a great variation in types of interventions reported in the included studies. These include clinician-delivered individual or group psychotherapy [ 39 , 40 , 45 , 46 ]; group-based module curriculum with components on discharge planning and release safety planning and coping, courtroom behavior, treatment compliance, mental health and substance abuse, anger management and conflict, effective communication skills [ 37 ]; adaptation of evidence-based treatment algorithms to improve clinical outcomes [ 36 ]; citizenship project including peer support, citizenship classes [ 43 ]; intermediate care programs to ease transitions from prison to the community [ 47 ]; a new model of care for broadened triggers for mental health referral [ 33 ]; wraparound case management and peer support services [ 35 ]; art brut therapy [ 42 ]; jail and court based diversion programs [ 41 ]; and mental health court [ 44 ]. All of these interventions were delivered at intercepts 3 and 4 (jail/court-based and during community reentry) in the sequential intercept model (see Table  3 ) [ 48 ]. None of the interventions addressed mental health concerns at earlier or later intercepts.

To synthesize interventions that were targeting individuals with SMI who have criminal legal involvement, a team of coders followed a thematic analysis to group interventions by categories. Interventions were grouped into five categories based on the modality, focus, and context of the interventions. These categories for modality included cognitive-behavioral, community-based, interpersonal, expressive therapy, and court-based interventions. Table  3 reports the interventions, categories for modality, description of each category, their frequencies across included studies. Due to methodological heterogeneity, not all studies reported effect sizes. However, for those studies that reported effect sizes, the effect sizes ranged from ( p  < 0.001) [ 36 ] to ( p  < 0.0001) [ 37 ].

Length of the intervention and the problems addressed

The length of intervention delivery varied across the studies ranging from 2 months to over a year. Only three of the studies described an intervention delivered for over a year [ 33 , 35 , 44 ]. Additional three studies reported interventions delivered for 7–12 months [ 41 , 42 , 43 ]. The rest of the studies reported the use of an intervention that was delivered for six months or under.

Presenting problems of participants across all articles were synthesized by each of the following categories: mental health, medical, substance use, or recidivism. All 13 studies reported mental health as a primary outcome. Additional outcomes reported include recidivism ( n  = 5, 38%), substance use ( n  = 4, 31%), and medical care ( n  = 1, 8%). Three of the articles included another option describing studies with a focus on additional presenting problems related to intimate partner violence, violence towards inmates, employment service utilization, and changes in social support. Of note, these summarized presenting problems were not mutually exclusive, with 54% of articles ( n  = 7) attempting to address multiple presenting problems. See Table  1 for information on all outcomes measured.

Barriers and facilitators to the implementation of interventions reported in the literature

Of the 13 articles included in this systematic review, 31% ( n  = 4) reported at least one barrier to implementing the intervention in criminal justice ( n  = 2) or community-based rehabilitation settings ( n  = 2). The reported barriers included lack of external policy and incentives (e.g., correctional/administrative policy, clinical culture in the correctional institutions [ 36 , 46 ], patient needs and resources, design quality and packaging, personal attributes of the study participants, implementation climate, and available resources. See Table  4 . Two studies reported barriers related to the inner and outer setting of interventions. Other studies reported barriers relating to the intervention process, characteristics of the individuals in the interventions, or a barrier that did not fall within the CFIR constructs (e.g., high staff turnover). Of note, there were no barriers reported related to the intervention characteristics.

• Facilitators

Four articles (30%) reported at least one facilitator for intervention implementation (Table  5 ) in criminal justice ( n  = 3) or community-based rehabilitation settings ( n  = 1). Guided by the CFIR framework, of the four studies that reported facilitators, one of them reported facilitators related to the intervention characteristics which included design quality and packaging, evidence strength and quality, cost, relative advantage, and adaptability. Three of the studies reported facilitators relating to the inner setting of the intervention, which included implementation climate [ 41 ], access to knowledge and information [ 41 , 46 ], available resources [ 43 ], and relative priority [ 46 ]. Five specific facilitators were reported more than once across studies, including implementation climate, knowledge and beliefs about the intervention, patient needs and resources, evidence strength and quality, and cost. Facilitators that were reported only once were related to intervention execution, personal attributes of the intervention participants, access to knowledge and information, available resources, design quality, relative advantage, and adaptability of the intervention.

The goal of the current paper was to systematically review the existing research on mental health interventions for individuals with serious mental illness who have criminal legal involvement. Given that the criminal legal system has become the country’s largest de facto provider of mental health services [ 8 ], there is a critical need to understand the effectiveness and implementation potential of evidence-based mental health interventions on individual mental health outcomes in these settings. Our review identified 13 studies that were found eligible for data extraction and reporting. Findings from synthesizing these literatures present mixed results, with some studies supporting the clinical utility and implementation potential of delivering interventions for individuals with SMI and criminal legal involvement, but others pointing to gaps in the extant literature and specific avenues for future research.

Of note, articles that were found eligible for this systematic review were somewhat nascent, beginning with a study developed in 1997. Additionally, there was significant heterogeneity among the research included in this review. Studies utilized a wide range of trial designs (e.g. RCTs, quasi-experimental, open trial) and focused on various mental health disorders as the primary outcome of interest. Across studies, however, all findings showed indications of positive influences on primary mental health outcomes, including improvement in depression, bipolar disorder, and PTSD symptoms. This should be interpreted with caution, as studies ranged in design and approach to measurement. Given that slightly less than 1% of individuals in America are currently incarcerated [ 49 ] and around 40% of those incarcerated in prisons have a mental health diagnosis [ 50 ], the consistency of these findings point to dissemination of interventions in criminal legal settings as an important tool for improving public health.

Interestingly, 11 of the studies found in our literature search had to be excluded as they did not include mental health as the primary outcome of a mental health intervention. In our review, IPT interventions constitute nearly a third of all interventions and were evaluated by a single investigator. Moreover, the majority of studies also reported a variety of secondary criminal legal, health services, and functional and behavioral health outcomes (e.g., recidivism, substance use, and engagement in medical care). While these studies largely found promising directions of the intervention’s influence for these other outcomes, the frequency of including outcomes that are adjacent to, but not directly related to the intervention, suggests a possible bias in the literature to focus on outcomes beneficial to society and less so for the population under study. This targeting of multiple problems and emphasis on multi-level approaches is important given that mental health concerns for criminal legal-involved populations is multifaceted and often involve multiple systems of care [ 19 ]. Nonetheless, our review suggests that research on the impacts of mental health interventions for people with SMI involved in some aspect of the criminal justice system could benefit from increased focus on mental health itself.

Results also point to the need for innovations around intervention delivery and the need for adopting interventions with strong evidence for improving mental health outcomes. Additionally, the majority of studies utilized mental health clinicians to deliver interventions; only three examined the efficacy of services delivered by non-clinical staff (in all of these cases, interventions were delivered by case workers). While this reflects long-standing divisions between professional roles, a growing literature points to the implementation potential of utilizing non-specialists to deliver interventions. For instance, a recent commentary suggests that individuals with lived experience with mental and behavioral health disorders and/or involvement in the criminal legal system, may be uniquely suited to support services for incarcerated individuals [ 51 ]. Peer-delivered interventions may be less stigmatizing [ 52 ] feasible within correctional settings [ 53 ], and have the potential to be cost-effective in resource limited contexts [ 54 ] including criminal legal contexts. An emerging body of literature also suggests that peers can deliver interventions with fidelity [ 55 ]. Given limitations to the reach and availability of specialist care relative to the mental and behavioral health needs of individuals in criminal legal settings, it will be important to explore alternative delivery approaches and workforces to increase access to Interventions, reduce mental health stigma and improve social norms around treatment engagement [ 56 ]. Moreover, the structural (e.g., restrictive prison policies that do not allow individuals with felony to be around others with criminal records) and individual (i.e., fear of stigma, relieving the trauma of incarceration) challenges of engaging formerly incarcerated individuals with SMI must be acknowledged.

The Sequential Intercept Model (SIM) maps points of intersection between individuals with mental and behavioral health needs and the larger criminal legal systems [ 22 , 48 ]. While the reentry and community corrections periods correspond to the final two points of intercept, the SIM also identifies four earlier points of intersection that may offer opportunities to deliver Interventions. For instance, none of the interventions reviewed above offer services when individuals first interact with local law enforcement (at the point of arrest) or during initial court hearings and detention, despite some evidence suggesting that individuals are at increased risk of suicide immediately after arrest and initial detainment [ 57 , 58 ]. Interventions at earlier intercepts are fewer likely due to the fact that a vast majority of individuals with SMI are unstably housed, hence, making it difficult to conduct multi-session interventions [ 59 ]. Moreover, shared sets of barriers were experienced across the interventions regardless of the intercepts targeted. This in part could be attributable to the fact that the criminal legal system is not set up to effectively respond to mental health care needs [ 60 , 61 ].

In this review, the types of interventions and the outcomes of interest seem to have varied along the lines of the study settings. Although mental health outcomes were the primary focus of the included studies, five of the studies evaluated criminal legal outcomes such as recidivism in addition to the mental health outcomes [ 35 , 37 , 41 , 43 , 44 ]. Another study evaluated the effect of an intervention on reducing serious problem behaviors within a correctional facility [ 42 ]. Studies focusing on the transition from correctional setting to the community targeted improvement in clinical outcomes, which in turn contribute to better service linkages, easier transitions and improvement in criminal legal outcomes.

The current review also focused on understanding the barriers and facilitators to implementing mental health interventions with individuals who have SMI and in criminal legal settings. It’s important to note that implementation of mental health interventions in criminal legal settings can be fraught with inner and outer context challenges related to low resources, lack of proper staffing and/or training, intervention characteristics misaligned with treatment needs, among others. These settings may also be highly controlled and restrictive, which may affect the extent to which interventions are adapted or tailored to be culturally responsive for individual needs [ 13 , 46 ]. Research guiding implementation of evidence-based mental health interventions in criminal legal settings is limited and far behind by comparison of work done in health systems. Yet, implementation is critical for accelerating uptake and maximizing sustainable, positive outcomes of mental health interventions. In an effort to understand the barriers and facilitators to implementing these interventions within criminal legal settings, the current review applied the CFIR framework to identify and categorize aspects of implementation across studies. Results highlight various elements related to implementation that can be used to further tailor implementation strategies to an organization’s context. Specifically, findings point to the inner setting and intervention characteristics as the most commonly cited facilitators, implicating the need to focus on these aspects during treatment adaptation to ensure an appropriate fit to the treatment context. Interestingly, however, no specific barriers or facilitators were identified by more than two studies. This indicates that a majority of studies did not report on implementation strategies, factors, or outcomes. This highlights the need for a standardized and consistent reporting of barriers and facilitators encountered during the implementation of interventions in these settings to inform future efforts. Additionally, only one study examined the cost-effectiveness of these approaches [ 40 ], underscoring the need for a robust design evaluating the costs associated with implementing mental health interventions in criminal legal settings.

Further, studies included in this review were exclusively from criminal legal settings in high-income countries. While many low- and middle-income countries (LMICs) have small prison populations, a number of risk factors inherent to these settings (including overcrowding, lack of resources, etc.) create further barriers to accessing mental health services [ 62 ]. Moreover, incarceration rates in low-and middle-income countries have been increasing [ 12 ]. Given that we found no intervention studies conducted in LMICs, there is a compelling need to examine the comparative efficacy and implementation potential of interventions in the U.S. to evaluate whether these approaches may meet the growing need for services within these criminal legal systems.

Limitations

While the reported results carry important implications for mental health in the criminal legal system, there are also some limitations worth stating. Our inclusion criteria focused on studies that are peer-reviewed, excluding other grey literature and unpublished reports, presenting a potential publication bias. Moreover, we were unable to find studies from LMICs that met our inclusion criteria. Therefore, the evidence must be interpreted with caution. Intervention studies focusing on serious mental illness in the criminal legal system in LMICs are needed.

Conclusions

Despite these gaps in the extant literature, this review provides support for both disseminating and implementing interventions for individuals with SMI who have criminal legal involvement. While future research is needed to examine how interventions could be delivered utilizing different workforces, at different points of intersection with the criminal legal system, and in other settings, results broadly highlight the promising implications of interventions for individuals with SMI who are criminal legal-involved. In turn, increasing access to evidence-based approaches has the potential to improve outcomes, disrupt cycles of reincarceration, and reduce the disproportionate burden of mental health disorders within the criminal legal system. More RCTs or other studies with fully powered samples, however, are needed to determine effectiveness in mitigating negative mental health outcomes for these populations.

Data availability

Systematic review protocol is available from the first author upon request.

Abbreviations

Consolidated Framework for Implementation Research

Consolidated Standards of Reporting Trials

Consolidated Criteria for Reporting Qualitative Research

Evidence-based interventions

High-income countries

Interpersonal Psychotherapy

Low- and middle-income countries

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Post-traumatic stress disorder

Randomized controlled trial

Strengthening the Reporting of Observational Studies in Epidemiology

Sequential Intercept Model

• Serious mental illness

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MH conceptualized the idea and designed the review protocol. JEJ and TEB contributed to the protocol development. TEB, BWM and MH conducted the initial title and abstract review. MH and TEB trained the review team. TEB managed the Qualtrics-based data extraction process. All authors participated in the review and extraction process. MH drafted the original manuscript. JF helped draft the discussion. All authors contributed to the manuscript, reviewed the draft, and approved the final version.

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Hailemariam, M., Bustos, T.E., Montgomery, B.W. et al. Mental health interventions for individuals with serious mental illness in the criminal legal system: a systematic review. BMC Psychiatry 24 , 199 (2024). https://doi.org/10.1186/s12888-024-05612-7

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