Introduction
The concept of “integrated and people-centred care” comprises two overarching concepts: integrated and people-centred care. The first concept, integrated care, is advanced from conventional illnesses-oriented and disease-focused health care. Illnesses-oriented care focuses on illness and cure, episodic consultation, and users as consumers purchase care. In contrast, disease-focused care refers to the management of diseases and priority disease control interventions, including their risk factors [
1]. Additionally, integrated care means putting people and communities (not diseases), at the centre of health systems and empowering people and communities to take charge of their health by ensuring well-coordinated care around their needs, responding to fragmentations of care, and improving quality and cost-effectiveness rather than being passive recipients of services [
1,
2].
Furthermore, integrated care emphasizes holistic care to improve population health and wellbeing with continued care across the life course, around needs with shared responsibility and accountability [
3]. Ensuring integrated care empowers people to tackle the determinants of ill-health through systems thinking and partnerships, encouraging them to become co-producers of care in multilevel (individual, organizational and policy) systems [
3]. Thus, integrated care is best understood as a set of practices intricately shaped by contextual factors to improve health status, and reduce morbidities and mortalities [
4].
Moreover, the second concept, i.e., people-centred care (PCC) is derived from patient and person-centred care. In the late 1960s, patient-centred care (different from illness-oriented care) was introduced and continued for several decades, opposing previously prevailing bio-medically oriented and paternalistic views of healthcare [
5]. Patient-centred care aims to make a functional life, affirming the ethical principles of respect for persons and justice, striving to make the health system more responsive to the health services needs [
5,
6]. Advocates of market solutions to healthcare have been adopting patient-centred care by arguing for improved flexibility of consumer-oriented health care options and enhancing individual choice [
7]. In contrast, person-centred care refers to caring for a meaningful life, and is a further development of patient-centred care based on personal philosophy, where the person denotes human and distinguishes from everything else [
5]. Primarily, PCC is an expansion of patient-centred/person-centred care where people are involved in a care cycle, including the public, healthcare practitioners, and care organizations or systems. The PCC focuses on organizing principles for integrated care as a service innovation relating to individual service users, families and concerned communities [
2]. Transforming the health care system towards people-centred health care requires action at four levels of the system: i) individuals, families and communities; ii) care providers; iii) health organizations; and iv) health systems [
8]. The PCC is associated with better care continuity, considered care delivery by frontline workers within the health system, and responsive care practices and service utilization [
9,
10].
The World Health Organization’s (WHO) Framework on integrated people-centred health services (IPCHS) combines the concepts of integrated care and people-centred care [
11]. The framework envisions that all people have equal access to quality health services, co-produces health care to meet their health needs across the life course and respect their preferences, and coordinated and quality care (comprehensive, safe, effective, timely, efficient, and acceptable) along the continuum by all skilled and motivated carers and work in a supportive environment [
11]. The conceptualization of integrated PCC puts people’s needs first in designing and delivering health services with principles of quality, safety, longitudinality (duration and depth of contact), closeness to communities, and responsive care (equity in access, quality, responsiveness and participation, efficiency, and resilience) [
12]. Specifically, the WHO framework on IPCHS outlines five interwoven strategies for management and health service delivery: engaging and empowering people and communities; strengthening governance and accountability; reorienting the model of care; coordinating services within and across sectors; and creating an enabling environment and funding support [
13,
14].
Primary health care (PHC) is a whole-of-society approach to organize and strengthen national health systems to bring health services closer to communities. The PHC approach comprises integrated health services to meet people’s health needs throughout their lives, addressing the broader determinants of health through multisectoral actions and empowering communities to improve health [
15]. While primary care is a first level of care, it is usually delivered from prehospital, peripheral health facilities, and community settings [
3]. People-centred PHC is the foundation of health systems that prioritize people first and have the potential to address diverse health needs by putting people and communities at the center of the system, empowering personalized health decision-making, and adapting health services to the local socio-cultural context [
16]. Current body of literature focuses on people-centred integrated health services, especially medical care in hospitals, or family medicine or care by general practitioners. Nonetheless, there is a dearth of research that synthesize standalone studies on people-centred PHC and primary care using the WHO’s IPCHS framework. Thus, this study aimed to synthesize evidence on people-centred PHC interventions and strategies, their issues, and challenges. The findings of this review could inform strategies for strengthening the health system towards people-centredness in PHC systems and delivery and utilization of services.
Methods
This study is a scoping review of the literature reporting people-centred PHC services/ primary care. A scoping review method helps to synthesize and analyze existing literature on a topic and map the scope of available evidence. The process involves six steps: identifying the research question; identifying relevant studies, selecting studies; charting data; collating, summarizing, and reporting results; and consultation (optional) [
17,
18]. We employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to support comprehensive reporting of methods and findings (Supplementary Information, Table S
1) [
19,
20].
Identifying the research question
We identified the research question focusing on people-centred PHC/primary care services. The key research question was to review and synthesize the evidence on issues and challenges related to people-centredness in PHC/primary care services. We brainstormed on two concepts: people-centred care and PHC/primary care. These concepts guided identifying search terms under each concept and developing search strings. Our research team assumed that the proposed research question is broad to provide a breadth of issues to be explored in the review. The research question was further clarified by preliminary discussion among authors and agreed on the scope and significance of the topic.
Identifying relevant studies
We searched eight databases (PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science, and Google Scholar). The search strategy was built on two key concepts and related search terms: People-centred care (patient centred care, people centred care, person centred care, patient-centred care, people-centred care, person-centred care, patient centered care, people centered care, person centered care, patient-centered care, people-centered care, client-centered care, client centered care, person-centered care); Primary Health Care (primary health care, public health care, community care, primary care, primary care nursing, family medicine, family practice, general practice) on each database. Boolean operators (AND/OR) and truncations (“”, *) varied depending on the database. The search included all studies published in English until 30 January 2023 (no starting date was applied in the search). No country-related limitations were applied.
Selection of studies
We included all studies that dealt with PCC regardless of their designs. Based on the title and abstract, screening was undertaken initially by the first author and further assessed by the second author. This was followed by a full-text screening initially by the first author and evaluated by the second and third authors. Any disagreements were resolved by discussion with the last author. We applied some post hoc inclusion and exclusion criteria based on the research question and new topic familiarity through reading the studies. For example, we included studies considering the population (health service users, care providers and managers), concept (PCC/integrated care), and contexts (PHC and primary care systems) of the study [
21]. We included studies if their findings can answer our review question rather than the quality of individual studies. We followed the standard scoping review PRISMA-ScR checklist [
19,
22] and took reference to previous scoping reviews [
23,
24]. The included studies are based on the findings and their interpretation rather than the inclusion criteria [
25,
26].
Charting the data
A data-charting form was developed to extract data from each study covering author, year, country, type of study, key concepts, and main findings (Supplementary file, Table S
2). Data were extracted by the first and double-checked by the second and last authors.
Collating, summarizing, and reporting results
The first author did data analysis with guidance and support from the last author. Thematic analysis of data was conducted by adopting Gale’s framework method [
27]. This analysis method adopts multiple steps such as collection of raw data (main findings about the research question for this review), familiarisation with data, paraphrasing of data/label according to the nature of data, developing/applying the analytical framework, charting data into the framework matrix, and finally interpretation. After reading and familiarisation the data, we extracted important concepts/categories and grouped them (with similar ideas) into the five components (engaging and empowering people and communities; strengthening governance and accountability; reorienting the model of care; coordinating services within and across sectors; creating an enabling environment and funding support) of the WHO ICPHS framework. Within each component, themes were generated by grouping similar categories/ideas and concepts. Findings were reported in three forms; first, outcomes of database search results were presented in the flow chart. Second, a customized summary of the data charting table (covering the author, location, and key ideas related to the research question) was presented. Finally, generated themes were explained and interpreted in the narrative paragraphs under each component of the analytical framework.
Discussion
This review synthesizes evidence on people-centred PHC and primary care. Major themes identified from this review were community engagement, empowerment and empathy, leadership and mutual accountability within the organization, home and community-based and participatory care, holistic care for people with multimorbidity, partnership with information technology, coordination and communication, and flexible management for delivery of people-centred PHC services. Most studies in the HICs explained people-centred medical care models with little focus research in LMICs.
There are several ways that health systems could generate and deliver people-centred and integrated care for individuals, families, and communities. Firstly, promoting respectful conversations and activities between care providers and service users is fundamental for improving community empowerment and ensuring providers’ empathy. People engagement and empowerment enhanced people-centred PHC in many contexts. Empowering traditionally disengaged communities and individuals requires awareness of social determinants of health [
80]. Conversation and engagement of people can support personalized, coordinated care towards narrowing inequalities [
81]. The provider’s empathy also enabled supportive, involved care, community, social enterprise, and volunteerism [
81]. Inter-professional teamwork and collaboration with and for older people and relatives are fundamental to empathy and empowerment [
66]. Of the five strategies of the WHO framework on IPCHS, community engagement and empowerment have little attention in the literature. The current global health initiatives, including the Asthana Declaration, have envisioned empowerment, health literacy, and understanding the public’s role in PHC [
82]; community engagement could potentially promote people-centred PHC service delivery. Thus, the focus of research, policy and practices of community engagement and empathy need to be prioritized in PHC and primary care in low-income settings.
Secondly, for PCC and coordinated care, there was an emphasis on organizational integrity and mutual accountability. Strengthening leadership and accountability in home-based care increased people-centred care in PHC services [
83]. Co-creation and healthcare organizations and their leadership efficiently could meet the health needs of people according to standards of care to align tactics and improve organizational reliability while paying attention to quality care [
84]. Organizational leadership and mutual accountability strategies could be beneficial in recruiting people with integrity and sensitivity, the ability to notice and respond through policies of diverse staff and aligning incentives and recognitions [
11,
84].
Thirdly, some models of care, such as care for people with multiple chronic conditions or comorbidities, residential home-based care, and participatory care, were effective approaches for PCC in PHC and primary care contexts. Such care models can effectively reduce the burden of hospitalization and care costs by using PHC and primary care in prehospital settings [
83,
85]. The residential home-based model of care facilitates holistic care through collaboration between family members and providers considering the family contexts and comprehensive education and care [
86]. Such a model is useful for people with multiple chronic conditions that could support the activities of daily living and produce high healthcare expenses. Functional limitations can often complicate access to health care, interfere with self‐management, and necessitate reliance on caregivers [
87]. Crucial for implementing people-centred care is knowing and confirming people as a whole and co-creating a tailored personal health plan [
66]. These residential care models could enhance the identification of health priorities (i.e., specific health outcomes and healthcare preferences), and clinicians align their decision-making to achieve these health priorities [
88].
Fourthly, partnership with the digital and information technology sector, and tools can potentially ensure coordinated care by monitoring health records, coordinating processes, tracking health services, and involving people representatives and individuals in developing digital services and work practices. The information technology-related stakeholders are vital for mutual information sharing and distributing initiatives, tasks, and responsibilities from providers to service users [
89]. The human-centred service design approach can leverage the potential of technology and advance healthcare systems, and innovative solutions for healthcare change and wellbeing; addressing the complexity of healthcare systems toward integrated care [
90].
Finally, enabling and flexibly managing the health system environment is fundamental for people-centredness in the provision of delivery of PHC services. System strengthening and management requires system inputs and processes towards desired outcomes. The structural factors of organizations and systems (e.g., creating a PCC culture across the continuum of care, co‐designing educational programs, health promotion and prevention programs with people) provide the foundation for PCC, providing a supportive and accommodating environment developing structures to support health information technology and measure and monitor people-centred care performance influence the processes and outcomes [
91]. The processes component describes the importance of cultivating communication and respectful and compassionate care, engaging service users in managing care and integrating care. At the same time, outcome domains identified include access to care and client-reported outcomes [
91]. At the system level, the enabling environment indicates the adaptation of responses, involvement in support, engagement with professionals, use of information and communication technologies, and organization of care [
92].
This study has some limitations. We included studies written only in English. This study is a scoping review of qualitative evidence in the topic. We synthesized evidence rather than grading the quality of available evidence. Synthesized evidence from this study could provide research, policy, and program insights for improved people-centred PHC services. Evidence generated from this study is primarily based on studies from HICs and upper-middle-income countries (UMICs), which can have limited contextual implications in low-income countries as the health systems contexts of LMICs are different. Therefore, future research can be conducted on specific components of people-centred care in low-income country settings.
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