Access to appointments and medicines was among the areas in which participants described improvements. Many said the “Mawid: My Appointment” system made it easier to book primary-care appointments, while “Wasfaty: My Prescription” improved access to medications for some users. These reported benefits did not extend uniformly across the patient population. Older adults and people with limited digital literacy or poor internet connectivity encountered additional barriers when using the digital services. Participants also raised practical concerns about limited parking, restricted appointment flexibility and long travel distances to obtain medications in some areas. The study therefore documents a combination of reported gains and continuing access problems, rather than a uniform experience of reform.

Patients emphasized the importance of relational continuity in primary care. They valued seeing the same physician over time and associated repeated contact with a familiar clinician with trust and familiarity. Frequent physician turnover was reported to weaken that continuity. Electronic medical records provided a different form of support by supporting informational continuity across providers, allowing patient information to remain available when care involved different clinicians. The focus-group findings distinguish these two aspects of continuity: participants appreciated both the transfer of clinical information and the personal familiarity developed through an enduring physician-patient relationship.

Coordination between primary and secondary care also showed a mixed picture. Participants reported that the “Ehalati: My Referral” system improved the speed of referrals and access to specialist care. Communication gaps between primary and secondary care providers nevertheless remained common. In primary health care centres, participants acknowledged greater availability of laboratory, X-ray, dental and mental health services, indicating improvements in the comprehensiveness of care available at this level. Availability within primary care centres did not mean that access was consistently straightforward. Long waiting times and limited appointment availability remained major concerns in dental care, while mental health services were described as less visible and inconsistently available.

As a qualitative focus-group study, the research cannot establish how common these experiences were among all Saudi patients or measure changes in service use, health outcomes or equity over time. The sample comprised 44 purposively recruited participants in 11 focus groups spanning four Saudi regions, and the conclusions are based on the themes that emerged from their accounts. Within that scope, the study documents how structural expansion and digital services coexist with uneven access, interruptions in continuity, communication failures between care levels and gaps in specialized services. The authors concluded that successful primary healthcare transformation requires more than structural and technological change, with sustained attention needed for equitable access, stable patient-provider relationships and integration across services.

Subject of Research: Patient experiences of primary healthcare reforms in Saudi Arabia

Article Title: Patients’ perspectives on primary healthcare reforms in Saudi Arabia: a qualitative focus group study

Article References: Mubarky, A., Almalki, M., Hulme, C., Valderas, J. M., Porter, I., Moafa, H. N., & Pitchforth, E. (2026). Patients’ perspectives on primary healthcare reforms in Saudi Arabia: a qualitative focus group study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15518-7

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15518-7

Keywords: Saudi Arabia, primary healthcare, healthcare reform, patient perspectives, focus groups, qualitative research, digital health, care continuity, referral coordination, healthcare access, Patients, perspectives

The analysis included 407 eligible adults from 413 completed questionnaires. Participants had a mean age of 32.1 years, with a standard deviation of 11.7, and 72.2% were female. Most were Saudi nationals, permanent residents of Makkah, urban residents, and educated to university or postgraduate level. Eight primary healthcare centers were selected through stratified random sampling across the city’s four geographical sectors, while individual patients were recruited by convenience sampling from waiting areas. Consequently, the results describe the participating primary-care population but are not population-representative estimates for all Makkah residents.

Researchers measured perceived shared decision-making with the validated nine-item SDM-Q-9, whose raw total of 0–45 was transformed to a 0–100 scale. Each item used a six-point response ranging from complete disagreement to complete agreement, with higher transformed scores indicating greater perceived involvement. The mean score was 53.99, with a standard deviation of 33.03 and a median of 55.56, suggesting moderate involvement overall but substantial variation between patients. Internal consistency was high for the questionnaire, with Cronbach’s alpha of 0.970.

Patient satisfaction was assessed with the validated Arabic version of the 18-item PSQ-18, covering general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with the doctor, and accessibility or convenience. Negatively worded items were reverse-scored so that higher totals consistently represented greater satisfaction. The mean total was 59.20 out of 90, with a standard deviation of 9.57. Communication received the highest mean domain score at 3.59, followed by general satisfaction at 3.56, while time spent with the doctor scored lowest at 2.94.

Before adjustment, shared decision-making and satisfaction had a weak positive rank correlation, with Spearman’s rho equal to 0.258 and P below 0.001. The researchers then used multivariable linear regression to account for age, sex, nationality, residency status in Makkah, area of residence, marital status, educational attainment, and frequency of healthcare visits. Because the regression diagnostics detected heteroscedasticity, the primary analysis used HC3 heteroscedasticity-consistent standard errors. In this model, a 10-point increase in SDM-Q-9 was associated with a 0.91-point higher PSQ-18 score, with a 95% confidence interval of 0.58–1.23 and P below 0.001.

The result remained similar under several alternative analyses. Conventional multivariable linear regression produced the same point estimate of 0.91, with a 95% confidence interval of 0.63–1.19. Adding the primary healthcare center as a fixed effect yielded a slightly smaller association of 0.86, with a 95% confidence interval of 0.52–1.21. Median quantile regression gave an estimate of 0.87, with a 95% confidence interval of 0.41–1.33. All three adjusted estimates had P values below 0.001, indicating that the direction and magnitude of the association were not materially altered by these analytical choices.

Secondary analyses examined whether shared decision-making scores were related to individual satisfaction domains. After adjustment for the same participant-level variables, a 10-point increase in SDM-Q-9 was associated with higher scores for general satisfaction, technical quality, communication, financial aspects, time spent with the doctor, and accessibility or convenience. The largest domain estimate was for communication, at 0.08 points per 10-point increase, followed by 0.07 for general satisfaction and 0.06 for technical quality. All six associations remained statistically significant after Benjamini–Hochberg false-discovery-rate correction. The association with interpersonal manner was not statistically significant, with an estimate of 0.01 and P of 0.212.

The item-level responses offered a more mixed picture of how shared decision-making unfolds in routine care. Patients were comparatively more likely to agree that their doctor helped them understand information, whereas active joint evaluation of treatment alternatives was less consistently reported. This distinction matters because shared decision-making involves more than information delivery: it includes exchanging information, discussing alternatives, considering patient preferences, and reaching a decision jointly. Favorable experiences were also evident in other parts of the survey, including explanations of medical tests and friendly treatment by doctors. At the same time, 27.5% strongly agreed that arranging an appointment was difficult, and 24.8% strongly agreed that emergency treatment required excessive waiting.

Exploratory analysis identified three participant characteristics associated with perceived shared decision-making, but the evidence for these subgroup patterns was less secure. Rural participants had scores about 13.09 points higher than urban residents, with a 95% confidence interval of 3.67–22.51 and P of 0.007. Saudi participants scored 8.41 points lower than non-Saudi participants, while single participants scored 9.04 points lower than married participants. Age, residency status, widowed or divorced status, education, and visit frequency were not significantly associated with SDM-Q-9 scores. The rural and non-Saudi subgroups contained only 37 and 48 participants, respectively, so these findings should be treated as hypothesis-generating rather than evidence of a durable demographic pattern.

Several limitations constrain how the findings can be interpreted. The cross-sectional design measured both shared decision-making and satisfaction during the same period, preventing the researchers from establishing temporal order or causality. Reverse causality is possible: patients satisfied with an encounter may also be more inclined to perceive or report greater involvement. The survey did not collect potentially important clinical or encounter-level factors, including illness severity, consultation type and duration, continuity with the physician, physician characteristics, and whether multiple reasonable treatment alternatives were available. Self-reporting may also have introduced recall, social-desirability, and common-method biases, while convenience recruitment and an unavailable systematic record of refusals left non-response bias unresolved.

Patient satisfaction is shaped by more than the decision-making conversation. The primary model explained 11.3% of the variation in PSQ-18 scores, with an adjusted R-squared of 8.6%, indicating that most differences remained unexplained. Access, waiting time, technical care, interpersonal conduct, continuity, and organizational factors may all contribute. The 0.91-point difference associated with a 10-point increase in SDM-Q-9 also cannot be assumed to be clinically important, because the study did not establish a minimal clinically important difference for the total PSQ-18 score. The findings therefore show a small, consistent association in a selected group of Makkah primary-care users, not proof that changing how decisions are made will automatically raise satisfaction. Prospective longitudinal and intervention studies would be needed to test that causal question.

Subject of Research: Association between perceived shared decision-making and patient satisfaction in Makkah primary healthcare

Article Title: Perceived shared decision-making (SDM) involvement and its association with patient satisfaction among primary healthcare visitors in Makkah city: a cross-sectional study

Article References: Alghamdi, A. A., & Alqurashi, J. H. (2026). Perceived shared decision-making (SDM) involvement and its association with patient satisfaction among primary healthcare visitors in Makkah city: a cross-sectional study. Frontiers in Medicine, 13, Article 1984378. https://doi.org/10.3389/fmed.2026.1984378

Image Credits: AI Generated

DOI: 10.3389/fmed.2026.1984378

Keywords: shared decision-making, patient satisfaction, primary healthcare, patient-centered care, Makkah, Saudi Arabia, cross-sectional study, healthcare communication, health services research, Perceived, shared, decision-making

The authors framed the review around an estimated 440 million people in India who require rehabilitation services, equivalent to 70% of South-East Asia’s total rehabilitation need. They noted that rehabilitation is an essential strategy for achieving universal health coverage and should be accessible to people with rehabilitation needs, while systematic information about public-system services was unavailable. The scope covered national and sub-national provision across primary, secondary and tertiary healthcare levels, with private-sector services excluded.

For the mapping review, researchers followed the established methodological framework for mapping reviews and reported the work under PRISMA-ScR 2020. Eligibility was structured with the Population–Concept–Context framework. The search covered PubMed, CINAHL and the Cochrane Library from their inception through September 2025, with English-language limits, and included screening of reference lists and consultation with experts. The researchers also hand-searched grey literature from Indian ministry, regulatory and international agency websites and the Shodhganga doctoral-theses repository. They included policy documents, national health programmes and empirical studies concerning rehabilitation service provision in India’s public health system at national and sub-national levels.

Of 820 records identified, including 549 from databases and 271 from grey literature, 32 sources met the inclusion criteria and informed the synthesis. These comprised four scientific studies and 28 grey-literature documents: 16 concerning disability and health programmes, nine concerning insurance and financial-assistance schemes, and three concerning accessibility mandates. Mapping and analysis used predefined themes based on the WHO Health Systems Building Blocks framework. The review found that rehabilitation was desirable at the secondary-healthcare level but virtually absent from primary healthcare, where the authors considered it most needed. Workforce estimates indicated severe shortages, including 0.58–0.88 rehabilitation personnel per 10,000 people at community health centres and 0.20 per 10,000 at district hospitals. The two most pronounced evidence gaps concerned the health workforce and health information systems. Based on this mapped evidence, the authors concluded that national and sub-national gaps warrant action to mandate rehabilitation as essential rather than merely desirable at primary-care level and move from disability-centred provision toward functioning-based services aligned with WHO Rehabilitation 2030. They also called for stronger evidence to support India’s National Rehabilitation Strategic Framework, while explicitly cautioning that the review did not assess implementation data.

Subject of Research: Mapping rehabilitation service provision and gaps across India’s public healthcare system

Article Title: Mapping of mandated Rehabilitation services in India’s public health system: opportunities for mainstreaming rehabilitation

Article References: Mullerpatan, R., Asheel, M., Tobgay, T., Rauch, A., Saini, R. K., Agarwal, B., Solomon, J., Babu, A. S., Ganesan, S., Kadam, N., Chhabra, H. S., Boominathan, P., Sinha, A. G. K., Bhise, A., Gupta, A., Daptardar, A., Chitnis, A., Bhagwat, C., Sharma, C., … Khalil, H. (2026). Mapping of mandated Rehabilitation services in India’s public health system: opportunities for mainstreaming rehabilitation. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15659-9

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15659-9

Keywords: rehabilitation services, public health system, primary healthcare, health workforce, health information systems, India, mapping review, universal health coverage, disability, Mapping, mandated, Rehabilitation

The research, published in BMC Medical Education by Mergan Naidoo and Kimera Tamzin Suthiram of UKZN’s Department of Family Medicine together with Lucie Byrne-Davis of the University of Manchester, set out to achieve stakeholder consensus on the core knowledge, skills, and attitudes required during the clinical years of undergraduate medical training. Rather than leaving curriculum decisions to a small committee or tradition, the team systematically mapped what was actually being taught, verified it with the academics responsible, and then subjected every item to a structured consensus process involving the people who use and depend on the curriculum: academic clinicians, recent graduates, and primary healthcare nurses.

The technical backbone of the study was a sequential mixed-methods design. First, the researchers conducted a documentary analysis of module templates, course materials, and curriculum mapping data to identify the existing content of the clinical years. This produced an inventory of 724 distinct curriculum items. To organise this vast catalogue, the team categorised each item according to the AfriMEDS framework, the Health Professions Council of South Africa’s adaptation of the Canadian CanMEDS competency model, which describes the multiple roles a medical practitioner must fulfil, from medical expert and communicator to health advocate and professional. The mapping revealed a striking imbalance: 653 of the 724 items aligned with the Healthcare Practitioner role, while only 71 items addressed the other AfriMEDS roles, a quantitative portrait of how heavily curricula lean toward pure clinical knowledge at the expense of broader professional competencies.

Because documentary analysis alone can miss what actually happens in teaching, the researchers then asked seventeen academic clinicians to verify the mapped content, confirming that the inventory reflected genuine curriculum rather than archival artefacts. This verification step matters enormously for the credibility of the final consensus: participants in the later Delphi rounds were judging a validated list, not a guess. The verified list then entered an electronic Modified Delphi process, a well-established technique for building group agreement without the distortions of face-to-face hierarchy, in which dominant voices or seniority can silence dissent. By running the process anonymously through an electronic platform, the team allowed a nurse in a primary healthcare clinic and a professor of medicine to carry equal weight.

Twenty-one participants completed the first Delphi round and seventeen completed the second, with consensus defined a priori as at least seventy percent agreement on each item. The process was genuinely two-directional: participants did not merely approve or reject existing content but proposed eight additional items they believed were missing, while seven duplicate items were removed during consolidation. In total, 725 unique knowledge, skills, and attitudes items were considered across the complete consensus process. The final verdict was decisive: 698 items achieved consensus for inclusion, comprising 629 aligned with the Healthcare Practitioner role and 69 with the other AfriMEDS roles, while 27 items failed to reach the agreement threshold and were excluded.

What makes the agreed content compelling is how closely it mirrors the epidemiology of South African healthcare. The consensus list reflected the major health priorities encountered in primary care and district health services, including communicable diseases such as HIV and tuberculosis that remain dominant burdens in the region, alongside the rapidly growing tide of non-communicable diseases like diabetes and hypertension. Maternal and child health, mental health, trauma, and emergency care all featured prominently, as did essential procedural skills, the hands-on capabilities a young doctor in a district hospital must possess when specialist backup is hours away. In other words, the curriculum that emerged is not a generic international checklist but a portrait of what a South African doctor actually faces on the ward and in the clinic.

The study’s context is central to its significance. Defining core curriculum content is a persistent challenge everywhere, but it is acute in resource-constrained settings where medical schools must balance an ever-expanding global knowledge base against pressing local healthcare priorities, often with limited faculty time and teaching infrastructure. Content overload is not merely an inconvenience; it dilutes learning, crowds out deep understanding, and can leave graduates theoretically encyclopaedic but practically unprepared for the conditions they will treat. By anchoring every curriculum decision to documented health system needs and a national competency framework, the UKZN team has demonstrated a way to make those trade-offs explicit, transparent, and defensible.

The methodological machinery behind the study also deserves attention. The researchers used REDCap, the Research Electronic Data Capture platform, to run the Delphi rounds, and drew on the institution’s Learning Opportunities, Objectives and Outcomes Platform for curriculum mapping, showing how existing educational technology can be repurposed for systematic curriculum reform. The Delphi technique itself, with its iterative rounds and quantified agreement thresholds, converts a notoriously subjective debate into a measurable process: every item’s fate is recorded, every dissent is visible, and the final curriculum carries an audit trail from initial mapping through verification to consensus. This is the kind of procedural rigour that curriculum committees, often operating under time pressure and political pressure, rarely achieve.

The implications extend well beyond Durban. The authors argue that their methodology and resulting framework offer a practical approach for other medical schools, particularly in low- and middle-income countries, to align curricula with community health needs while maintaining competency-based educational principles. Globally, medical education is shifting toward competency-based models and entrustable professional activities, frameworks that specify what a doctor should be trusted to do rather than merely what courses they have attended. But such frameworks only work if their content is defined locally and legitimately, which is exactly what this study delivers: a stakeholder-informed, consensus-verified core that respects both international competency standards and the realities of district hospitals and community clinics.

There is also a quiet democratic principle embedded in the work. By including recent graduates, who remember what the curriculum failed to teach them, and primary healthcare nurses, who see firsthand where new doctors stumble, the study widened the circle of curriculum authority beyond the professoriate. The result is a core curriculum with 698 items that earned the confidence of the people who teach, practice alongside, and depend on South Africa’s future doctors. As medical schools worldwide grapple with information overload and calls to decolonise and contextualise their teaching, this South African study offers a template: map what you teach, verify it with those who teach it, and let a structured consensus of stakeholders decide what truly belongs at the core.

Subject of Research: Stakeholder consensus on core curriculum content for clinical years of undergraduate medical education

Article Title: Gaining stakeholder consensus on core curriculum content for the clinical years of undergraduate medical education at the University of KwaZulu-Natal, South Africa: a mixed-methods study

Article References: Naidoo, M., Suthiram, K. T., & Byrne-Davis, L. (2026). Gaining stakeholder consensus on core curriculum content for the clinical years of undergraduate medical education at the University of KwaZulu-Natal, South Africa: a mixed-methods study. BMC Medical Education. https://doi.org/10.1186/s12909-026-10629-5

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10629-5

Keywords: medical education, core curriculum, Delphi technique, mixed-methods research, competency-based education, AfriMEDS, curriculum mapping, South Africa, University of KwaZulu-Natal, primary healthcare, undergraduate medical training, stakeholder consensus

The scientific rationale for the trial rests on a well-documented gap between international guidance and frontline practice. The World Health Organization’s 2013 Clinical and Policy Guidelines on Responding to Intimate Partner Violence and Sexual Violence Against Women recommend integrating violence response into primary healthcare services, yet the mechanics of achieving this integration in low- and middle-income country settings remain poorly understood. Health facilities in such settings often lack trained staff, clear protocols, private consultation spaces and reliable referral pathways, all of which are prerequisites for a survivor to safely disclose abuse and receive meaningful help. Udaan is designed to close this evidence gap by rigorously evaluating not just whether an integrated response works, but how it can be implemented and sustained within the constraints of a real public health system.

Methodologically, the trial adopts a cluster randomised controlled design with a randomized block structure, a choice that reflects the reality that health interventions operate at the level of facilities and communities rather than individuals. Two randomly selected blocks in the Chhatrapati Sambhajinagar district of Maharashtra will serve as the intervention area, while comparable areas will act as controls. Randomising at the cluster level helps prevent contamination between groups, since it would be nearly impossible to train health workers in one facility while keeping neighbouring facilities untouched. The trial is registered with the Clinical Trial Registry of India under number CTRI/2024/07/071367, having been registered on 26 July 2024, with enrolment beginning on 1 October 2024 and recruitment ongoing.

The intervention itself is a multi-layered package targeting several pillars of the health system simultaneously. At its core is capacity building: training health workers and community health workers to recognise the signs of violence, respond with empathy and confidentiality, and connect survivors to appropriate support. Alongside training, the intervention addresses structural barriers by improving patient flow to protect privacy and confidentiality, establishing clear clinical protocols for handling disclosures, documenting cases systematically, and strengthening referral mechanisms that link health facilities to police, legal aid and shelter services. This systems-level approach reflects a growing consensus in global health that one-off training sessions rarely change practice unless the surrounding infrastructure supports and rewards the new behaviours.

To measure effectiveness, the researchers will conduct cross-sectional surveys among women visiting health facilities in both the intervention and control arms, at baseline and again at end line, eighteen months after the intervention begins. This before-and-after, two-arm comparison will allow the team to estimate whether the integrated response is associated with a reduction in domestic violence in the communities served by the intervention facilities. Measuring violence reduction through a health system intervention is ambitious, and the survey design acknowledges that any observed change must be interpreted against the backdrop of secular trends, seasonal variation and the inherent sensitivity of asking women about experiences of abuse in clinical settings.

Because the intervention depends heavily on the people delivering it, the trial includes dedicated measurement of workforce change. A knowledge, attitude and practice survey will assess whether capacity building actually shifts what health workers know, how they think about violence, and what they do when survivors present. In parallel, a facility readiness assessment will evaluate whether the systems strengthening components, from private consultation rooms to functioning referral directories, have been put in place and are being used. Together these two instruments provide a mechanistic picture: if violence outcomes change, the researchers will be able to trace whether that change travelled through improved provider competence, improved facility structures, or both.

Qualitative methods round out the evaluation design. In-depth interviews and focus group discussions with health workers will explore their perceptions of the intervention’s relevance and their lived experience of implementing it, capturing the friction points that quantitative surveys inevitably miss. The study will also employ dedicated methodology to establish the cost of the health system response to domestic violence, an element that is critical for policy makers weighing whether such programmes can be scaled across India’s vast public health infrastructure. Cost data from rigorously evaluated trials are scarce in this field, and their absence has long hampered advocacy for budget allocations to violence response services.

The stakes of the trial are considerable in the Indian context, where national data sources such as the National Family Health Survey and the National Crime Records Bureau document high and persistent levels of violence against women, while healthcare providers operate under a legal and policy mandate to respond to domestic violence that is frequently unfulfilled in practice. The authors argue that the findings will help operationalise this mandate, clarifying what is required at the level of the health system, including the distinctive role that community health workers can play in prevention. Community health workers occupy a trusted, door-to-door position in Indian villages and urban settlements, and their involvement represents an innovative extension of violence response beyond clinic walls into the spaces where abuse often first unfolds.

The trial has passed a demanding gauntlet of ethical oversight, with approvals from CEHAT’s Program Development Committee, the independent Anusandhan Trust Ethics Committee registered with India’s Ministry of Health, a technical review panel of the WHO’s Human Reproduction Programme, the WHO Ethics Review Committee, and the Institutional Review Boards of the George Washington University. All respondents will provide informed consent before participating in interviews, focus groups or surveys, a safeguard of particular importance in research where disclosure of violence carries real risks. The work is funded by the United Kingdom’s Foreign, Commonwealth and Development Office through the Global Women’s Institute at the George Washington University, with additional support for several authors from the UNDP/UNFPA, UNICEF, World Bank and WHO Special Programme of Research on Human Reproduction.

If Udaan demonstrates that a strengthened primary health system can reduce domestic violence, the implications will ripple far beyond one district in Maharashtra. Governments across South Asia and other low- and middle-income regions would gain a tested, costed blueprint for converting their own clinics and community health networks into first lines of defence against abuse, fulfilling obligations that international guidelines have long articulated but rarely resourced. Conversely, if the trial shows null or mixed results, the detailed process measures, qualitative findings and cost data will still illuminate precisely where the health system model falls short, steering the field toward more promising strategies. Either way, the study promises to move the conversation about violence against women from rhetorical commitment to empirical evidence, and its progress will be watched closely by researchers, advocates and policy makers around the world.

Subject of Research: Health system response to and prevention of domestic violence in primary healthcare in India

Article Title: Udaan: scaling up health system response to and prevention of domestic violence: Protocol of a cluster randomised trial

Article References: Arora, S., Rege, S., Jain, K., Ellsberg, M., Meyer, S. R., Thwin, S. S., Meinhart, M., & Amin, A. (2026). Udaan: scaling up health system response to and prevention of domestic violence: Protocol of a cluster randomised trial. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15586-9

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15586-9

Keywords: domestic violence, violence against women, cluster randomised trial, primary healthcare, health system strengthening, community health workers, India, Maharashtra, WHO guidelines, public health, study protocol, trial registration

The research team, led by Ludovic Deo Gracias Tapsoba of Joseph Ki-Zerbo University in Ouagadougou and including collaborators from Ghana, the United Kingdom and Canada, set out to fill a stubborn evidence gap. Burkina Faso has national policies on adolescent health, but little facility-level data existed on whether the primary healthcare facilities that serve as the main entry point for these services actually have the staff, equipment and medicines to deliver them. The study focused on two purposively selected regions, Centre-Ouest and Hauts-Bassins, chosen to capture different geographic and epidemiological contexts in the western and southwestern parts of the country.

Within those regions, the researchers randomly selected health districts and then sampled facilities by systematic random sampling proportional to size, a design intended to give larger facility networks a fair chance of inclusion while preserving statistical representativeness. The final sample of 152 facilities was dominated by Health and Social Promotion Centers, the community-level facilities that constitute the backbone of Burkina Faso’s primary care system, which accounted for 77.6 percent of the surveyed sites. Medical centers and medical centers with surgical units made up the remainder, alongside a small number of private and faith-based facilities.

To measure capacity, the team adapted the World Health Organization’s Service Availability and Readiness Assessment tool, a standardized instrument used across low- and middle-income countries to benchmark health facility performance. Availability was assessed across three service domains: family planning, sexual health education and rights, and antenatal care. Readiness was measured across three parallel dimensions: trained personnel, diagnostic capabilities and essential medicines. The study’s headline metric, full availability, was an all-or-nothing composite requiring every component across all three domains to be present in a single facility. That conservative construction means the 30.3 percent figure should be read as a floor for comprehensive service delivery rather than a conventional coverage indicator.

The urban-rural divide was the study’s most statistically robust finding. Full availability was significantly higher in urban facilities than in rural ones, at 46.5 percent versus 23.9 percent, a between-group difference with a 95 percent confidence interval of 5.7 to 39.6 and a p-value of 0.006. In a country where the majority of adolescents live outside cities, that gap matters. A teenager in a rural village is roughly half as likely to find a clinic equipped to provide the complete package of adolescent sexual and reproductive health services as a teenager in an urban center, even when both clinics report offering some services.

Readiness gaps were even more pronounced than availability gaps, particularly for diagnostic capacity and staff training. Syphilis-testing capacity was very low overall and significantly higher in urban than rural facilities, at 23.2 percent versus 4.6 percent, with a 95 percent confidence interval of 7.1 to 33.4 and a p-value of 0.001. Congenital syphilis remains a preventable cause of stillbirth and neonatal death across sub-Saharan Africa, so the near-absence of testing capacity in rural clinics represents a concrete clinical risk. Staff recently trained in refocused antenatal care, a WHO-endorsed model that concentrates visits around evidence-based interventions, were also more common in urban areas, at 53.4 percent versus 33.0 percent, with a 95 percent confidence interval of 3.1 to 37.8 and a p-value of 0.020.

Not every comparison reached statistical significance. Full availability did not differ significantly between the two regions, at 28.6 percent in Centre-Ouest versus 32.0 percent in Hauts-Bassins, with a p-value of 0.65, suggesting the problem is systemic rather than confined to one geographic area. Differences across facility types were based on small subgroups and should be interpreted with caution, the authors note. The broader pattern, however, points to particular weakness in Health and Social Promotion Centers and in private and faith-based facilities, which are precisely the sites that rural adolescents are most likely to encounter first.

The study’s implications reach beyond Burkina Faso. Across West Africa, adolescent sexual and reproductive health remains one of the most politically and culturally contested areas of public health, and facility-level evidence of this kind is rare. The research was supported by a grant from the UK Medical Research Council and the Foreign, Commonwealth and Development Office, in collaboration with the UK Department of Health and Social Care, reflecting growing international investment in the ADOWA initiative, which examines adolescent mental, sexual and reproductive health policy and primary care implementation priorities across the region. Ethical approval was granted by Burkina Faso’s National Ethics Committee for Health Research, and all facility data were anonymized before analysis.

What makes the findings actionable is the specificity of the readiness gaps. The authors identify in-service training, particularly in refocused antenatal care, as a priority, alongside strengthening the availability of family planning methods and adolescent education activities in rural areas. For Health and Social Promotion Centers and private facilities, the priorities are more infrastructural: clinical guidelines, diagnostic capacity and reliable supply chains. These are not exotic interventions. They are the unglamorous plumbing of a health system, and the study suggests that in Burkina Faso that plumbing is leaking at exactly the joints where adolescent patients pass through.

The timing is significant. Burkina Faso’s adolescent population is growing, and the country faces overlapping pressures from insecurity and displacement that strain rural health services. As the authors conclude, availability and readiness of primary healthcare facilities to provide full adolescent sexual and reproductive health services remain limited, especially in rural facilities and in the community-level centers that dominate the primary care landscape. For a health system built on the promise that every clinic is a doorway to care, the study is a reminder that a doorway is only useful if the room behind it is equipped. The full open-access article, with complete subgroup comparisons by region, facility type and residence, is available online.

Subject of Research: Health Services Research

Article Title: Availability and readiness of primary healthcare facilities in the provision of adolescent sexual and reproductive health services in two regions of Burkina Faso: a cross-sectional study

Article References: Tapsoba, L. D. G., Amenah, M. A., Traoré, S., Da Silva, R. B., & Meda, Z. C. (2026). Availability and readiness of primary healthcare facilities in the provision of adolescent sexual and reproductive health services in two regions of Burkina Faso: a cross-sectional study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15649-x

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15649-x

Keywords: Burkina Faso, adolescent health, primary healthcare, reproductive health, family planning, health facilities, rural health, West Africa, Availability, readiness, primary, healthcare

The study, conducted across healthcare facilities in Saudi Arabia’s Eastern Province, surveyed 227 nurses working in four distinct clinical environments: critical care units, inpatient wards, outpatient clinics, and primary healthcare centres. The researchers combined a twenty-item knowledge test with a ten-item self-efficacy questionnaire adapted from an instrument first developed by Roh and colleagues, which showed strong internal consistency in this sample. Alongside the survey, they carried out twenty-two semi-structured interviews to probe the lived experiences behind the numbers, analysing the transcripts using a well-established thematic framework.

The statistical picture that emerged was consistent in direction but modest in magnitude. Knowledge and self-efficacy moved together: nurses who scored higher on the CPR knowledge test also reported greater confidence in their resuscitation abilities, a correlation that was highly statistically significant. Yet knowledge accounted for only about one-tenth of the variation in self-efficacy, meaning that the vast majority of what shapes a nurse’s confidence lies outside the boundaries of what a written test can capture. This finding alone carries an important implication for training programmes, because it suggests that simply teaching more facts about resuscitation algorithms will not, by itself, produce nurses who feel ready to lead or participate in a resuscitation attempt.

The differences between settings were striking on both measures. Critical care nurses recorded the highest self-efficacy scores, while their counterparts in outpatient clinics scored lowest, and the gap between these groups was substantial relative to the spread of scores within each group. Knowledge scores also varied by setting, though the differences were somewhat less pronounced. The researchers used analysis of variance with post-hoc comparisons to confirm that these were not chance findings, and the effect sizes they reported indicate that setting explains a meaningful, if partial, share of the variability in both outcomes.

One methodological caveat deserves attention. The researchers estimated how much of the variation in outcomes could be attributed to the clustering of nurses within settings, a quantity known as the intraclass correlation coefficient. Their point estimate was low, but because only four setting categories were available for this calculation, the confidence interval around the estimate was extremely wide. The authors themselves describe this figure as exploratory, and readers should treat it as a rough indication rather than a precise measurement. What it does suggest is that individual characteristics, such as prior experience, personal confidence, and recent exposure to real resuscitation events, likely matter more than the setting label itself.

The qualitative interviews added depth that the numbers alone could not provide. Six themes emerged from the analysis. The most prominent was that direct clinical exposure to real resuscitation events was the primary driver of self-efficacy: nurses who had recently participated in or witnessed an actual cardiac arrest response reported markedly greater confidence than those whose experience was limited to classroom scenarios. This aligns with a broader body of psychological research on self-efficacy, which holds that mastery experiences, meaning successful direct performance of a task, are among the most powerful influences on a person’s belief in their own capability.

The second theme concerned fear of error and the dynamics of the resuscitation team. Nurses described how anxiety about making a mistake, particularly in front of senior colleagues or physicians, could undermine their willingness to act even when they possessed the relevant knowledge. Team hierarchy, communication patterns, and the perceived consequences of speaking up all shaped whether a nurse felt able to contribute during an actual emergency. These findings echo long-standing observations in resuscitation research about the role of psychological safety in team performance during high-stakes events.

A third theme revealed a disconnect between how training is delivered and what it is meant to achieve. Many participants described pursuing CPR certification as a box-ticking exercise, a requirement to be completed rather than a genuine opportunity to build competency. This perception, the authors suggest, may explain why knowledge scores did not translate more strongly into confidence: if training is experienced as a formality, its content may not be deeply integrated into clinical practice or self-belief.

The fourth theme identified institutional support and structured debriefing as the factors that separated high-performing settings from low-performing ones. Units where resuscitation events were routinely followed by a reflective discussion of what went well and what could be improved tended to produce nurses with stronger self-efficacy. Debriefing after real events is well recognised in the resuscitation literature as a mechanism for consolidating learning, reducing emotional distress, and improving future team performance, and this study suggests its benefits extend to nurses’ confidence as well as their skills.

The fifth theme touched on psychological and emotional determinants, including the emotional weight of participating in resuscitation attempts, the fear of patient harm, and the lingering effects of difficult experiences. The sixth theme reinforced the idea that context matters: the same nurse may feel and perform differently depending on the environment in which they work, the resources available, and the frequency with which emergencies arise.

Taken together, the findings point toward a reframing of how resuscitation preparedness is understood and cultivated. The authors conclude that differences across settings cannot be explained by knowledge deficits alone, and that psychological and organisational factors contribute substantially. Their recommendations focus on two practical interventions: simulation-based training tailored to the needs of outpatient and primary care environments, where real resuscitation events are rare and experience accumulates slowly, and the establishment of routine debriefing practices after actual resuscitation events. Both recommendations are consistent with international resuscitation council guidance, which has increasingly emphasised the value of realistic rehearsal and structured reflection alongside traditional knowledge transmission.

For outpatient clinics and primary healthcare centres, the challenge is particularly acute. Nurses in these settings may go months or years without encountering a cardiac arrest, yet when one occurs they are often the first responders, and the outcome may depend on their readiness in those first critical minutes before advanced support arrives. Infrequent real-world exposure means that simulation becomes not a supplement but a substitute, the only reliable way to maintain the familiarity and confidence that critical care nurses develop through daily practice. The study’s finding that outpatient nurses scored lowest on both knowledge and self-efficacy suggests that current training provision in these settings is not closing that gap.

The study also carries implications for how healthcare organisations measure preparedness. Because the researchers explicitly note that clinical performance was not measured, only knowledge and perceived confidence, the findings should be read as a portrait of preparedness rather than a direct assessment of resuscitation quality. Nevertheless, the strong association between the two constructs, and the clear setting-level differences, provide administrators with a practical signal: where self-efficacy is low, it is worth investigating whether the underlying causes are educational, psychological, or organisational, since each calls for a different remedy.

The research was conducted in the Eastern Province of Saudi Arabia, a region with a well-developed healthcare infrastructure that includes tertiary cardiac facilities, general hospitals, and an extensive network of primary healthcare centres. The authors report that the study received no external funding and that it was approved by three separate institutional review boards covering all participating sites, with the study conducted in accordance with the Declaration of Helsinki. The reporting follows established guidelines for cross-sectional studies and for the qualitative component, and the mixed-methods design adheres to recognised criteria for studies of this type.

As with any cross-sectional design, the study captures a single moment in time and cannot establish whether low self-efficacy causes poorer resuscitation performance, whether infrequent exposure erodes confidence, or whether both are shaped by some third factor such as organisational culture. The authors are careful to frame their conclusions in these terms. What the study does establish is that preparedness, as measured by knowledge and confidence, is unevenly distributed across the healthcare system, and that the unevenness follows a pattern closely tied to clinical exposure and institutional support. For health systems seeking to improve survival from cardiac arrest, the message is that investment in simulation and debriefing, particularly in settings where real emergencies are rare, may yield returns that classroom instruction alone cannot deliver.

Subject of Research: CPR knowledge and resuscitation self-efficacy among nurses across different healthcare settings in Saudi Arabia

Article Title: CPR knowledge and resuscitation self-efficacy among nurses across diverse healthcare settings in Saudi Arabia: a mixed-methods cross-sectional study

Article References: Almualem, J., Alabdulbaqi, D., Alzain, F., Bazboz, M., Zahran, A., Alsaffar, Z., Almzain, J., Almansour, L., Alzaher, A., Altalaq, H., Bawady, A., Alhabib, Z., & Alsulaiman, M. (2026). CPR knowledge and resuscitation self-efficacy among nurses across diverse healthcare settings in Saudi Arabia: a mixed-methods cross-sectional study. BMC Nursing. https://doi.org/10.1186/s12912-026-05312-5

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05312-5

Keywords: CPR, resuscitation, nursing, self-efficacy, Saudi Arabia, cardiac arrest, mixed-methods, primary healthcare, clinical training, simulation, debriefing, BMC Nursing

The intervention, known as the Early Childhood Development Parenting Readiness Education Program, or ECD PREP, was embedded directly into the flow of primary healthcare services. Rather than asking parents to attend separate classes at distant venues, the program integrated responsive caregiving education into the same visits where mothers already receive antenatal care, delivery services, and postnatal care. This design choice matters technically: it exploits existing contact points between families and the health system, which is precisely where scalability becomes possible in resource-constrained settings.

Responsive caregiving during the earliest years of life is considered foundational by developmental scientists. The concept covers a parent’s ability to read an infant’s cues, whether a cry signals hunger, discomfort, or overstimulation, and to answer those signals promptly and appropriately. Decades of research link this pattern of interaction to stronger physical growth, cognitive attainment, and socio-emotional adjustment, and it strengthens the parent-child relationship at a stage when the brain is developing at its fastest rate. Healthcare settings, the study’s authors argue, can serve as a hub for promoting and scaling up responsive caregiving among parents who might otherwise never encounter such guidance.

To test whether clinic-based education could actually shift these behaviors, the research team recruited 423 participants, 324 from Pakistan and 99 from Afghanistan, across six field sites, four in Pakistan and two in Afghanistan. The sites were assigned using a controlled allocation: two Pakistani fields and one Afghan field delivered the intervention, while an equal number served as control sites offering standard care. Participants were enrolled through convenience sampling, and the study formed the sequential mixed-method arm of a broader implementation research effort led by teams at Aga Khan University in Karachi and Aga Khan Health Services in Kabul, with funding from the Aga Khan Foundation’s Foundations for Health and Empowerment initiative in partnership with Global Affairs Canada.

The quantitative battery was deliberately multi-dimensional. Parenting confidence was measured with the Karitane Parenting Confidence Scale, a validated instrument that captures a parent’s self-assessed competence in soothing, feeding, and understanding their infant. Overall wellbeing was assessed with the World Health Organization Quality of Life scale, and newborn responsive interaction was scored with the ECD PREP newborn responsive interaction scale, which evaluates observable dimensions of parent-infant exchange. A basic demographics questionnaire rounded out the instruments. Quantitative data were analyzed in SPSS, while qualitative interviews with parents and healthcare professionals were analyzed manually to extract themes about the program’s perceived value.

The numbers tell a striking story. Parents who received the clinic-based education scored significantly higher on parenting confidence than controls, 34.57 plus or minus 6.44 versus 32.52 plus or minus 6.3, a mean difference of 2.05 with a p-value below 0.001. The gap on newborn responsive interaction was even larger in practical terms: 17.89 plus or minus 2.32 in the intervention group against 15.37 plus or minus 4.33 among controls, a mean difference of 2.52, again with p below 0.001. Notably, the standard deviation among intervention parents was roughly half that of the control group on the interaction scale, suggesting that the program did not merely lift the average but also narrowed the spread, raising the floor for parents who might otherwise have struggled most with reading infant cues.

The qualitative interviews added texture that the statistics alone cannot convey. Parents described the intervention as beneficial in two specific ways: it taught them what responsive parenting actually looks like in daily practice, and it helped them develop strong attachment with their newborns. Healthcare professionals, for their part, agreed that the program enhanced their own skills and knowledge in responsive caregiving, an important secondary finding because it indicates the education flows in both directions. When clinic staff feel more capable of coaching families, the intervention becomes self-reinforcing rather than dependent on a single training event.

These results carry weight beyond the study sites. Pakistan and Afghanistan together account for a substantial share of the world’s children growing up in conditions where early stimulation and responsive care are rarely discussed in formal terms, and where the health system is often the only institution in regular contact with new mothers during the first weeks of life. By demonstrating that a continuous, structured parenting education stream can be run inside existing primary healthcare infrastructure, the study provides a template that other low- and middle-income countries could adapt without building new programs from scratch. The finding that confidence and interaction both improved also aligns with a broader technical principle in behavior change: self-efficacy and practice tend to rise together when education is repeated across multiple routine contacts rather than delivered once.

The authors are careful about the study’s design boundaries. Convenience sampling means the participants were not randomly drawn from the general population, and the allocation of sites rather than individuals introduces the possibility of site-level differences influencing outcomes. The published version is also an early-release, peer-reviewed accepted manuscript that remains subject to further editorial refinement. Still, the consistency of the quantitative differences across two countries, combined with converging qualitative themes from both parents and healthcare professionals, strengthens the case that the observed effects reflect the intervention itself rather than local idiosyncrasies.

The study’s central conclusion is direct: a continuous structured parenting education intervention in healthcare settings can improve parental practices in ways that contribute to optimal child development. The authors therefore emphasize the need to integrate parenting education programs at all levels of healthcare settings, from community outreach to facility-based services. For the 423 families who took part, the program changed how they responded to their newborns in the earliest days of life. For health systems across the region, the message is that the same clinics already delivering vaccines and postnatal checkups can, with modest additions, become the front line of the science of responsive caregiving, turning every routine visit into an opportunity to build the parent-child bond that underpins a lifetime of development.

Subject of Research: Pediatrics

Article Title: Newborn parenting education in primary healthcare settings of Pakistan and Afghanistan: impact on confidence and interactions

Article References: Bhamani, S., Nadeem, S., Shams, M., Tikmani, S. S., Aslam, K., Choudhry, S., Jiwa, B., Maab, A., & Delawar, G. (2026). Newborn parenting education in primary healthcare settings of Pakistan and Afghanistan: impact on confidence and interactions. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07587-8

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07587-8

Keywords: responsive caregiving, parenting education, primary healthcare, early childhood development, Pakistan, Afghanistan, newborn care, parent-child interaction, Newborn, parenting, education, primary

The research, conducted by Tianran Wang and Zhongjin Yao of the School of Public Health and Management at Guangzhou University of Chinese Medicine, focuses on county-level medical alliances, the networks that link county hospitals with township health centers in an effort to redistribute medical expertise downward. Vertical collaboration in these alliances refers to cooperation across the hierarchical tiers of the system: specialists and administrators at the county level working with frontline clinicians at the township level. On paper, such alliances are meant to harmonize referrals, training, quality control and resource sharing. In practice, the researchers argue, collaboration often remains shallow, sustained more by administrative mandate than by the intrinsic motivation of the medical personnel involved.

To understand why, the authors grounded their work in the organizational collaboration theory developed by Denise D’Amour and colleagues, a framework widely used in health services research to decompose collaboration into its underlying dimensions. From that theoretical base, Wang and Yao constructed what they call the CLFI vertical collaboration theoretical framework. Within this framework, they identified ten dimensions as antecedent conditions, meaning factors that plausibly set the stage for strong or weak collaboration. These dimensions include shared goals and a patient-centered orientation, alongside other elements spanning the structural, cognitive and relational layers of how county and township personnel interact.

With the framework in place, the team designed a questionnaire and administered it through random sampling within a single county-level medical alliance in Fujian Province, in southeastern China. The survey achieved a valid response rate of 96.95 percent, an unusually high figure that suggests the instrument reached a large share of the target population. Rather than treating each respondent’s answers as independent data points to be averaged, the researchers used fuzzy-set qualitative comparative analysis, or fsQCA, a method that treats combinations of conditions rather than individual variables as the objects of analysis.

FsQCA deserves a technical explanation because it is central to the study’s contribution. Rooted in the mathematics of set theory, fsQCA evaluates how far each case belongs to particular sets, for example the set of respondents reporting high trust or the set reporting high collaboration capacity, assigning fuzzy membership scores that can range from fully out to fully in. The method then searches for configurations, which are specific combinations of conditions that are consistently associated with the outcome of interest. This makes it well suited to questions of the kind Wang and Yao posed, because collaboration is almost certainly equifinal: there may be several distinct recipes for success rather than a single dominant cause.

The analysis delivered exactly that kind of plural answer. From the data, the researchers extracted eight different configuration combinations of causal conditions, which they then synthesized into five broader capability enhancement paths. They named these the policy-driven path, the functional synergy path, the service-oriented path, the innovation-driven path and the relationship-building path. The consistency of the solutions across these five combinations of conditions reached 82.2 percent, a measure indicating how frequently, in the fuzzy-set sense, the identified configurations align with high vertical collaboration capacity.

Each of the five paths carries its own logic. The policy-driven path emphasizes coordinated rules, incentives and institutional arrangements as the engine that pulls county and township personnel into alignment. The functional synergy path highlights the professional division of labor and mutual capacity support, so that each tier of the alliance contributes complementary functions rather than duplicating or competing with the other. The service-oriented path embeds patient outcomes throughout the processes of collaborative goal setting, process design and performance evaluation, making the benefits to patients the organizing principle of joint work. The innovation-driven path calls for a tolerance and assessment mechanism that provides pilot support and dynamic monitoring for collaborative innovation, allowing personnel to experiment without fear that a failed experiment ends the partnership. The relationship-building path, finally, foregrounds the consolidation of mutual trust among county and township medical personnel.

The practical recommendations that follow from the findings are correspondingly multi-pronged. The authors argue that strategic policy coordination should be strengthened so that directives aimed at county hospitals and those aimed at township centers do not pull in different directions. Cognitive linkages between the two tiers should be enhanced, so that personnel understand and internalize each other’s roles and constraints. Patient outcomes, in their view, should not be an afterthought but a thread running through goal setting, process design and evaluation. Innovation needs institutional protection through tolerance and assessment mechanisms, and trust needs deliberate cultivation alongside a clear professional division of labor. Taken together, these moves are intended, in the study’s framing, to promote the medical community’s transition from spontaneous cooperation to conscious coordination, with the ultimate aim of improving the quality and efficiency of primary healthcare services.

Why does this matter beyond one county in Fujian? China’s health reforms have invested heavily in county-level medical alliances, also discussed in the literature under the umbrella of integrated delivery networks, precisely because grassroots institutions often lose patients to large urban hospitals, weakening both primary care and system sustainability. If vertical collaboration between county and township personnel is the mechanism through which expertise and standards flow downward, then understanding the configurational causes of strong collaboration speaks directly to whether those reforms deliver. The study’s message is that single-lever interventions, such as a new referral protocol or a training program, may fail not because the idea is wrong but because the supporting configuration of conditions is incomplete. A policy push without trust, or a shared mission without functional complementarity, may simply not generate the collaboration capacity reformers expect.

Methodologically, the study also illustrates why fsQCA is gaining ground in health services research. Traditional regression-based approaches estimate the independent effect of each variable, which can obscure the way conditions interact or substitute for one another. FsQCA, by contrast, accepts that the same outcome can arise through different routes and analyzes cases as wholes. The authors’ use of the method within a D’Amour-based theoretical framework offers a template for studying collaboration in other settings, from hospital mergers to multidisciplinary tumor boards. The study was supported by the 2024 Guangdong Province Graduate Education Innovation Program Project of China, and the authors report no competing interests. For the doctors, nurses and managers who populate China’s county alliances, the research suggests a hopeful conclusion: better vertical collaboration is achievable, but only when policy, cognition, service goals, innovation support and trust are assembled together, in whichever combination a given alliance can realistically build.

Subject of Research: Pathways to improve vertical collaboration capacity of medical personnel in Chinese county-level medical alliances using the CLFI model and fsQCA

Article Title: Study on pathways to improve the capacity for vertical collaboration of medical personnel in county-level medical alliances: an empirical exploration based on the CLFI collaboration model

Article References: Wang, T., & Yao, Z. (2026). Study on pathways to improve the capacity for vertical collaboration of medical personnel in county-level medical alliances: an empirical exploration based on the CLFI collaboration model. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15813-3

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15813-3

Keywords: county-level medical alliance, vertical collaboration, medical personnel, CLFI collaboration model, fuzzy-set qualitative comparative analysis, D'Amour collaboration theory, primary healthcare, health services research, fsQCA, China health reform, Fujian Province, patient-centered care

The argument advanced by Cele and Sujee arrives at a moment when health workforce planners across the region are rethinking what competence actually means for cadres who were, from their inception, designed to serve communities rather than hospitals. Clinical Officers first appeared in Uganda in 1918 and Kenya in 1928, when colonial administrations confronted the arithmetic of serving vast rural populations with very few physicians. That origin matters for how professionalism is understood today. The cadre was never conceived as a junior version of the doctor but as a distinct clinical practitioner whose legitimacy rests on proximity to communities, practical skill, and the ability to function within health systems that have always been resource-constrained. South Africa’s Clinical Associate programme, formalised more recently as a three-year bachelor’s degree regulated by the Health Professions Council of South Africa, represents a later iteration of the same workforce logic, though with a narrower scope of practice and closer oversight by medical practitioners. Malawi, Tanzania, and Zambia each developed their own variants, producing a family of cadres that differ in training pathways and regulatory arrangements but share a common frontline mandate.

This heterogeneity is one reason the authors resist treating professionalism as a single exportable template. A Clinical Officer in rural Malawi who performs emergency surgical procedures operates under conditions that differ profoundly from those facing a Clinical Associate in a South African district hospital, yet both navigate professional hierarchies in which their authority may be questioned by patients, colleagues, and institutions. Dominant professionalism frameworks, which typically enumerate observable behaviours such as punctuality, honesty, and respectful communication, offer little guidance for negotiating these structural realities. The authors argue that such frameworks, rooted in biomedical and competency-based traditions, individualise what are actually systemic problems. When a practitioner works in a facility without reliable supplies, or when patients arrive with advanced disease because transport and referral systems failed them, lapses that assessment tools might code as unprofessional conduct often reflect the conditions of practice rather than deficiencies of character.

The theoretical core of the paper draws on Paulo Freire, the Brazilian educator whose critique of banking education reshaped adult learning theory in the latter twentieth century. Freire’s central insight was that education either domesticates or liberates: it either transmits knowledge as a deposit to be received passively, or it cultivates critical consciousness, the capacity to perceive and interrogate the social conditions that shape one’s life. Applied to health professions education, this distinction is consequential. A curriculum that teaches professionalism as a checklist of attributes produces practitioners who can perform the role as defined by others. A curriculum grounded in dialogue and praxis, by contrast, invites trainees to examine why their communities carry the disease burden they do, why referral systems fail, and why the health workforce itself is distributed so unevenly. Praxis, in Freire’s formulation, joins reflection with action, meaning that critical understanding is incomplete unless it informs how practitioners actually engage their circumstances.

The authors pair Freire with Ubuntu, the Southern African ethical tradition often summarised in the phrase umuntu ngumuntu ngabantu, roughly rendered as a person is a person through other persons. Where Freire contributes the critical edge, a refusal to accept inequity as natural, Ubuntu contributes the relational foundation: the understanding that identity and moral obligation are constituted through community rather than achieved by individuals in isolation. Bringing these traditions into conversation is not merely decorative. It grounds the proposed reconceptualisation of professionalism in intellectual resources indigenous to the region, which is itself a decolonial move. Professionalism scholarship has been dominated by frameworks developed in North American and European contexts, and importing them wholesale risks reproducing the very hierarchies of knowledge that colonial health systems established. The authors position their framework as relational, contextual, political, and emancipatory, four adjectives that each carry weight. Relational acknowledges that care happens between people embedded in communities. Contextual insists that professional conduct cannot be judged apart from material conditions. Political recognises that health inequities are produced by decisions, not accidents. Emancipatory points toward education that expands rather than constrains what practitioners can perceive and do.

The historical framing the authors provide deserves particular attention. Before colonialism, health and healing across much of the continent were embedded in community life and indigenous knowledge systems, with care inseparable from social relationships and local understandings of wellbeing. Colonial administrations reorganised health services around particular forms of knowledge and authority, creating hierarchies that persist in contemporary systems. Post-independence governments responded with the primary health care movement, emphasising community participation, equity, and accessibility, and training community health workers to reach populations that colonial and, in South Africa’s case, apartheid systems had marginalised. Clinical Officers and Clinical Associates emerged within this lineage as cadres explicitly designed to extend care to underserved communities. Their professionalism, the authors contend, cannot be understood apart from this history, because the very existence of the cadre is a response to structural inequity.

The practical implications the authors identify extend across curriculum design, faculty development, assessment, and professional identity formation. Each of these domains currently operates on assumptions that the critical framework challenges. Curricula that present professionalism as a fixed set of attributes would need to create space for students to analyse the social and political determinants of health they encounter daily in clinical placements. Faculty development would require educators themselves to develop critical consciousness, since teachers steeped in competency-based frameworks may struggle to facilitate dialogue about power and inequity. Assessment poses perhaps the thorniest problem: professionalism is typically evaluated through observable behaviours and standardised instruments, and measuring critical engagement with structural conditions resists the psychometric tools available. The authors do not claim to have solved these measurement challenges, but their conceptual analysis makes visible what current approaches leave unexamined.

It is worth situating this argument within broader currents in health professions education research. Over the past two decades, scholars have increasingly questioned whether professionalism can be reduced to individual attributes, pointing instead to organisational culture, hidden curricula, and systems factors as powerful shapers of conduct. Social accountability has gained traction as a criterion for evaluating medical schools, particularly those serving populations with the greatest health needs. Decolonial critiques of curriculum have moved from the margins to the centre of educational scholarship in the global South, questioning whose knowledge counts and whose epistemologies structure training. The paper by Cele and Sujee contributes to these conversations by applying them to a cadre that has been largely absent from the professionalism literature despite its centrality to frontline care across the region. Mid-level practitioners deliver a substantial share of clinical services in many Sub-Saharan African countries, yet the frameworks guiding their professional formation were largely developed for and by the medical profession in very different contexts.

The emphasis on professional identity formation also carries significance for workforce retention, a persistent challenge in health systems marked by shortages. Practitioners whose training fosters a sense of purpose connected to community wellbeing may be more likely to remain in underserved postings than those whose identity is anchored in aspirations modelled on specialist medicine. If professionalism education helps trainees find meaning in the realities of frontline practice rather than framing those realities as deficits to be overcome, it may contribute to sustaining the workforce that primary healthcare depends on. This connection between identity, meaning, and retention is not the authors’ central claim, but it follows naturally from their argument that professionalism is socially situated.

As a perspective piece, the article advances a conceptual argument rather than reporting empirical findings, and its proposals will require testing in actual training programmes. The questions it raises, however, are answerable through research: how CA/CO students experience professionalism curricula, what happens when dialogue about structural conditions enters the classroom, how assessment instruments might be adapted, and whether graduates trained under critical frameworks practise differently in measurable ways. The authors’ contribution lies in articulating a theoretically coherent alternative and demonstrating that the intellectual resources for such an alternative, Freirean pedagogy joined with Ubuntu, are neither foreign nor abstract but rooted in the educational and ethical traditions of the region the cadre serves. Whether training institutions adopt this reframing will depend on regulatory bodies, faculty capacity, and political will, but the paper establishes that the current frameworks are a choice rather than a necessity, and that another conceptualisation of professionalism is available to those who train the practitioners holding up primary healthcare across Sub-Saharan Africa.

Subject of Research: Critical pedagogy approaches to professionalism in clinical associate and clinical officer training in Sub-Saharan Africa

Article Title: A critical pedagogy approach to reimagining professionalism in clinical associate/clinical officer training in Sub-Saharan Africa

Article References: Cele, E., & Sujee, N. (2026). A critical pedagogy approach to reimagining professionalism in clinical associate/clinical officer training in Sub-Saharan Africa. Frontiers in Medicine, 13, Article 1983787. https://doi.org/10.3389/fmed.2026.1983787

Image Credits: AI Generated

DOI: 10.3389/fmed.2026.1983787

Keywords: clinical associates, clinical officers, critical pedagogy, professionalism, health professions education, Sub-Saharan Africa, Paulo Freire, Ubuntu, social accountability, decolonial theory, primary healthcare, medical education