Using multiple lenses to explore how an undergraduate curriculum supports pharmacy students’ patient-centred competency development
DOI:
https://doi.org/10.46542/pe.2022.221.727743Keywords:
Competency, , Curriculum mapping, Equity, Patient-centered care, Person-centered care, Pharmacy educationAbstract
Background: This study explores how a Bachelor of Pharmacy curriculum supports students’ holistic patient-centred competency development.
Methods: This mixed-method exploratory study identified patient-centred care themes through a literature review. The themes were mapped to a curriculum. They also informed staff and student focus groups, and student, intern, and preceptor surveys. Qualitative data were thematically analysed, descriptive statistics were generated from quantitative data and the findings triangulated.
Results: Six themes and 22 subthemes were identified and mapped. Attributes synthesised from subthemes, were explored via surveys. Eight staff and 20 students participated in four focus groups. The influence of people, immersive learning experiences and learning variety were identified as key facilitators for competency development. 51 students, 18 interns and 51 preceptors completed the questionnaires. The responses validated the themes and attributes and identified curricular strengths and gaps.
Conclusion: A multi-step study incorporating triangulation generated a comprehensive and confirming overview of curriculum components, which led to pharmacy students’ development of patient-centred competencies.
References
Abuzour, A., Lewis, P., & Tully, M. (2018). Practice makes perfect: A systematic review of the expertise development of pharmacist and nurse independent prescribers in the United Kingdom. Research in Social and Administrative Pharmacy, 14(1), 6-17. https://doi.org/10.1016/j.sapharm.2017.02.002.
Aspden, T., Butler, R., Heinrich, F., Harwood, M., & Sheridan, J. (2017). Identifying key elements of cultural competence to incorporate into a New Zealand undergraduate pharmacy curriculum. Pharmacy Education, 17(1), 43-54. https://pharmacyeducation.fip.org/pharmacyeducation/article/view/477
Aspden, T., Sheridan, J.L., & Harrison, J. (2016). “Talking and thinking”: The impact of a simulation on pharmacy undergraduates’ beliefs and attitudes about living in poverty. Currents in Pharmacy Teaching and Learning, 8(4), 447-457. https://doi.org/10.1016/j.cptl.2016.03.016
Association of American Colleges and Universities & Carnegie Foundation for the Advancement of Teaching. (2004). A statement on integrative learning: Washington, DC. http://wacenter.evergreen.edu/sites/wacenter.evergreen.edu/files/statementintlearning.pdf
Austin, Z. (2016). How to design and use learning objectives in clinical teaching. Pharmaceutical Journal, 296(7885), 46-48. https://pharmaceutical-journal.com/article/ld/how-to-design-and-use-learning-objectives-in-clinical-teaching#main-content
Barnett, N. (2017). Developing a Person-Centred approach to Pharmacy Practice. Unpublished Thesis by Publication, Kingston University, Surrey.
Barry, M., & Edgman-Levitan, S. (2012). Shared decision making - the pinnacle of patient-centered care. New England Journal of Medicine, 366(9), 780-781. https//doi.org/10.1056/NEJMp1109283
Bengtsson, M. (2016). How to plan and perform a qualitative study using content analysis. Nursing Plus Open, 2, 8-14. https://doi.org/10.1016/j.npls.2016.01.001
Bengtsson, M., & Ohlsson, B. (2010). The nursing and medical students motivation to attain knowledge. Nurse Education Today, 30(2),150-156. https://doi.org/10.1016/j.nedt.2009.07.005
Berger, B. (2009). Patient-centered care: It's about time. American Journal of Pharmaceutical Education, 73(5) Article 91. https//doi.org/10.5688/aj730591
Boud, D., Keogh, R., & Walker, D. (1985). Reflection: Turning Experience into Learning. London: Kogan Page.
Bradley, F., Steven, A., & Ashcroft, D. M. (2011). The role of hidden curriculum in teaching pharmacy students about patient safety. American Journal of Pharmaceutical Education, 75(7), Article 143. https:/doi.org/10.5688/ajpe757143
Brewer, E. W., & Burgess, D. N. (2005). Professor's role in motivating students to attend class. Journal of STEM Teacher Education for Health, 42(3), Article 3. https://ir.library.illinoisstate.edu/jste/vol42/iss3/3
Buetow, S. (2011). Person-centred care: Bridging current models of the clinician-patient relationship. The International Journal of Person Centered Medicine, 1(1), 196-203. https://doi.org/10.5750/ijpcm.v1i1.46
Caffarella, R. (2002). Devising Transfer-of-Learning Plans. In R. Caffarella (Ed.), Planning Programs for Adult Learners: A Practical Guide for Educators, Trainers, and Staff Developers (2nd ed) (pp. 203-223). San Francisco, CA: Jossey-Bass.
Caffarella, R., & Barnett, B. (1994). Characteristics of adult learners and foundations of experiential learning. New Directions for Adult and Continuing Education, 94(62), 29-42. https://doi.org/10.1002/ace.36719946205
Canadian Pharmacists Association. (2015). Blueprint for Pharmacy: Transition in a New Era. Ottawa: Canadian Pharmacists Association. https://www.pharmacists.ca/cpha-ca/assets/File/pharmacy-incanada/blueprint/Blueprint%20Transition%20Report_2015_ENG.pdf
Collins, A. (2014). Measuring what really matters: Towards a coherent measurement system to support person-centred care. London: The Health Foundation. https://www.health.org.uk/publications/measuring-what-really-matters-towards-a-coherent-measurement-system-to-support-person-centred-care
Constand, M., J. , MacDermid, V., Bello-Haas, D., & Law, M. (2014). Scoping review of patient-centered care approaches in healthcare. BMC Health Services Research, 14, 271. https//doi.org/10.1186/1472-6963-14-271
Coulter, C., & Ellins, J. (2006). Patient-focused interventions. A review of the evidence. London: The Health Foundation. https://www.health.org.uk/sites/default/files/PatientFocusedInterventions_ReviewOfTheEvidence.pdf
Cram, F. (2014). Improving Māori access to health care: Research report. Auckland: Katoa Ltd. https://www.moh.govt.nz/notebook/nbbooks.nsf/0/211DA45C5EA63205CC257DD8007AE977/$file/Access_ResearchReport.pdf
Cruess, R. L., Cruess, S. R., & Steinert, Y. (2016). Amending Miller’s Pyramid to Include Professional Identity Formation. Academic Medicine, 91(2), 180-185. https//doi.org/10.1097/ACM.0000000000000913
Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., et al. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health,18, 174. https//doi.org/ 10.1186/s12939-019-1082-3
Davies, B., Leung, A., & Dunne, S. (2012). So how do you see our teaching? Some observations received from past and present students at the Maurice Wohl Dental Centre. European Journal of Dental Education, 16(3), 138-143. https://doi.org/10.1111/j.1600-0579.2012.00733.x
Editorial Board. (2020). Taking urgent action on health inequities [Editorial]. The Lancet, 395(10225). https://doi.org/10.1016/S0140-6736(20)30455-4
Ellins, J., & Coulter, C. (2005). How engaged are people in their health care? Findings of a national telephone survey. Oxford: Picker Institute Europe. https://www.health.org.uk/publications/how-engaged-are-people-in-their-healthcare
Elvey, R., Hassell, K., Lewis, P., Schafheutle, E., Willis, S., & Harrison, S. (2015). Patient-centred professionalism in pharmacy: values and behaviours. Journal of Health Organization and Management, 29(3), 413-430. https//doi.org/10.1108/JHOM-04-2014-0068
Ewen, S., Mazel, O., & Knoche, D. (2012). Exposing the hidden curriculum influencing medical education on the health of Indigenous people in Australia and New Zealand: the role of the Critical Reflection Tool. Academic Medicine, 87(2), 200-205. https//doi.org/10.1097/ACM.0b013e31823fd777
Gillespie, R., Florin, D., & Gillam, S. (2004). How is patient‐centred care understood by the clinical, managerial and lay stakeholders responsible for promoting this agenda? Health Expectations, 7(2), 142-148. https//doi.org/10.1111/j.1369-7625.2004.00264.x
Goodyear-Smith, F., & Ashton, T. (2019). New Zealand health system: universalism struggles with persisting inequities. The Lancet, 394(10196), 432-442. https//doi.org/10.1016/S0140-6736(19)31238-3
Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: a movement in crisis? British Medical Journal, 348, g3725. https//doi.org/10.1136/bmj.g3725
Haack, S. (2008). Engaging pharmacy students with diverse patient populations to improve cultural competence. American Journal of Pharmaceutical Education, 72(5), Article 124. https//doi.org/10.5688/aj7205124
Hafferty, F. W. (1998). Beyond curriculum reform: confronting medicine's hidden curriculum. Academic Medicine, 73(4), 403-407. https//doi.org/10.1097/00001888-199804000-00013
Hafferty, F. W. (2009). Professionalism and the socialization of medical students. In R. L. Cruess, S. R. Cruess & Y. Steinert (Eds.), Teaching Medical Professionalism (pp. 53–73). New York: Cambridge University Press. https://doi.org/10.1017/CBO9780511547348.005
Hao, M. (2017). The rise of patient-centred technologies in community pharmacy. The Pharmaceutical Journal https//doi.org/10.1211/PJ.2017.20202232
Harden, R. (1999). What is a spiral curriculum? Medical Teacher, 21(2), 141–143. https://doi.org/10.1080/01421599979752
Harden, R. M. (2001). AMEE Guide No. 21: Curriculum mapping: a tool for transparent and authentic teaching and learning. Medical Teacher, 23(2), 123-137. https//doi.org/10.1080/01421590120036547
Hasan, S. S., Wong, P. S., Ahmed, S. I., Chong, D. W. K., Mai, C. W., Pook, P., et al. (2013). Perceived impact of clinical placements on students' preparedness to provide patient-centered care in Malaysia. Currents in Pharmacy Teaching and Learning, 5(4), 303-310. https//doi.org/10.1016/j.cptl.2013.01.010
Health and Disability System Review. (2020). Health and Disability System Review – Final Report –Pūrongo Whakamutunga Wellington: HDSR. https://systemreview.health.govt.nz/assets/Uploads/hdsr/health-disability-system-review-final-report.pdf
Health Innovation Network. (ND). What is person-centred care and why is it important? South London: Health Innovation Network. https://healthinnovationnetwork.com/resources/what-is-person-centred-care/
Health Quality and Safety Commission. (2019). A window on the quality of Aotearoa New Zealand's health care 2019. Wellington Health Quality and Safety Commission. https://www.hqsc.govt.nz/resources/resource-library/a-window-on-the-quality-of-aotearoa-new-zealands-health-care-2019-a-view-on-maori-health-equity-2/
Health Quality and Safety Commission. (2021). Bula Sautu – A window on quality 2021: Pacific health in the year of COVID-19. Wellington: Health Quality & Safety Commission. https://www.hqsc.govt.nz/resources/resource-library/summary-bula-sautu-a-window-on-quality-2021-pacific-health-in-the-year-of-covid-19-whakarapopotanga-bula-sautu-he-mata-kounga-2021-hauora-pasifika-i-te-tau-covid-19/
Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK222274/
Jacob, S. A., & Boyter, A. C. (2020). Survey of undergraduates' perceptions of experiential learning in the MPharm programme: The TELL Project. Pharmacy Practice (Granada), 18(2), 1856. https//doi.org/10.18549/PharmPract.2020.2.1856
Jones, R., Pitama, S., Huria, T., Poole, P., McKimm, J., Pinnock, R.,(2010). Medical education to improve Māori health. New Zealand Medical Journal, 123(1316), 113-122.
Khangura, S., Konnyu, K., Cushman, R., Grimshaw, J., & Moher, D. (2012). Evidence summaries: the evolution of a rapid review approach. Systematic Reviews, 1(10), 9. https//doi.org/10.1186/2046-4053-1-10
Kitson, A., Marshall, A., Bassett, K., & Zeitz, K. (2013). What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. Journal of Advanced Nursing, 69(1), 4-15. https//doi.org/10.1111/j.1365-2648.2012.06064.x
Kremer, L. J., Nguyen, A. L. A., Waaka, T., A., Tutbury, J., Wilby, K. J., & Smith, A. (2021). To what extent does a pharmacy curriculum foster diversity and inclusion through paper-based case scenarios?. Pharmacy Education, 21(1), 612-620. https://doi.org/10.46542/pe.2021.211.612620
Lee, C. (2016). The move to patient centered pharmacy: How to get there from here." Health IT Outcomes https://www.healthitoutcomes.com/doc/the-move-to-patient-centered-pharmacy-how-to-get-there-from-here-0001.
Little, P., Everitt, H., Williamson, I., Warner, G., Moore, M., Gould, C., et al. (2001). Preferences of patients for patient centred approach to consultation in primary care: observational study. British Medical Journal, 322(7284), 468-472. https//doi.org/10.1136/bmj.322.7284.468
Luxford, K., Safran, D., & Delbanco, T. (2011). Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. International Journal for Quality in Health Care, 23(5), 510-515. https//doi.org/10.1093/intqhc/mzr024
Mauri Ora Associates. (2010). Best health outcomes for Pacific Peoples: Practice implications. Wellington: Medical Council of New Zealand.
Mead, N., & Bower, P. (2000). Patient-centredness: a conceptual framework and review of the empirical literature. Social Science & Medicine, 51(7), 1087-1110. https//doi.org/10.1016/s0277-9536(00)00098-8
Mead, N., & Bower, P. (2002). Patient-centred consultations and outcomes in primary care: a review of the literature. Patient Education and Counseling, 48(1), 51-61. https//doi.org/10.1016/s0738-3991(02)00099-x
Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Academic Medicine, 65(9), S63-S67.https//doi.org/10.1097/00001888-199009000-00045
Minister of Health. (2016a). New Zealand Health Strategy: Future direction. Wellington. https://www.health.govt.nz/system/files/documents/publications/new-zealand-health-strategy-futuredirection-2016-apr16.pdf
Minister of Health. (2016b). New Zealand Health Strategy: Roadmap of actions 2016. Wellington: Minitry of Health. https://www.health.govt.nz/system/files/documents/publications/new-zealand-health-strategy-roadmapofactions-2016-apr16.pdf
Ministry of Health. (2014a). Equity of Health Care for Māori: A framework. Wellington: Ministry of Health. https://www.health.govt.nz/publication/equity-health-care-maori-framework
Ministry of Health. (2014b). The Guide to He Korowai Oranga: Māori Health Strategy 2014. Wellington. https://www.health.govt.nz/publication/guide-he-korowai-oranga-maori-health-strategy
Ministry of Health. (2014c). Tagata Pasifika in New Zealand. Wellington: Ministry of Health. https://www.health.govt.nz/our-work/populations/pacific-health/tagata-pasifika-new-zealand#overall
Ministry of Health. (2016). Pharmacy Action Plan: 2016-2020. Wellington: Ministry of Health. https://www.health.govt.nz/publication/pharmacy-action-plan-2016-2020
Ministry of Health. (2019). Achieving Equity. https://www.health.govt.nz/about-ministry/what-we-do/work-programme-2019-20/achieving-equity
Ministry of Health. (2020a). Annual Update of Key Results 2019/20: New Zealand Health Survey. Wellington: Ministry of Health. https://www.health.govt.nz/publication/annual-update-key-results-2019-20-new-zealand-health-survey.
Ministry of Health. (2020b). Te Tiriti o Waitangi framework. Wellington: Ministry of Health. https://www.health.govt.nz/system/files/documents/pages/whakamaua-tiriti-o-waitangi-framework-a3-aug20.pdf
Ministry of Health. (2020c). Wai 2575 Health Services and Outcomes Kaupapa Inquiry. Wellington: Ministry of Health. https://www.health.govt.nz/our-work/populations/maori-health/wai-2575-health-services-and-outcomes-kaupapa-inquiry
Ministry of Health. (2020d). Whakamaua: Māori Health Action Plan 2020–2025. Wellington: Ministry of Health. https://www.health.govt.nz/publication/whakamaua-maori-health-action-plan-2020-2025
Ministry of Social Development. (2016). New Zealand Disability Strategy: 2016 - 2026. Wellington, New Zealand. https://www.odi.govt.nz/assets/New-Zealand-Disability-Strategy-files/pdf-nz-disability-strategy-2016.pdf
Muzyk, A., Lentz, K., Green, C., Fuller, S., May, B., & Roukema, L. (2017). Emphasizing Bloom’s affective domain to reduce pharmacy students’ stigmatizing attitudes. American Journal of Pharmaceutical Education, 81(2), Article 35. https//doi.org/10.5688/ajpe81235
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. (2017). The Root Causes of Health Inequity. In Baciu A, Negussie Y, Geller A & W. JN. (Eds.), Communities in Action: Pathways to Health Equity. Washington (DC): National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK425848/
NEJM Catalyst. (2017). What is patient-centred care? https://catalyst.nejm.org/what-is-patient-centered-care/.
Nevins Stanulis, R., & Guenther, A. R. (2021). A call for curriculum and faculty developers to attend to ambitious teaching in experiential curriculum. Medical Science Educator, 31(1), 223-228. https//doi.org/10.1007/s40670-020-01162-1
Nolte, E., & Anell, A. (2020). Person-centred health systems: strategies, drivers and impacts. In J. A. North, E. Nolte, S. Merkur & A. Anell (Eds.), Achieving Person-Centred Health Systems: Evidence, Strategies and Challenges (European Observatory on Health Systems and Policies) (pp. 41-74). Cambridge: Cambridge University Press.
O'Neill, N. (2015). The eight principles of patient-centered care. http://www.oneviewhealthcare.com/the-eight-principles-of-patient-centered-care/.
Orsini, C., Evans, P., & Jerez, O. (2015). How to encourage intrinsic motivation in the clinical teaching environment?: a systematic review from the self-determination theory. Journal of Educational Evaluation for Health Professions, 12, 8. https//doi.org/10.3352/jeehp.2015.12.8
Ozolins, I., Hall, H., & Peterson, R. (2008). The student voice: recognising the hidden and informal curriculum in medicine. Medical Teacher, 30(6), 606-611. https//doi.org/10.1080/01421590801949933
Pharmaceutical Society of New Zealand and New Zealand Medical Association. (2016). An Integrated Framework for Pharmacists and Doctors: consultation draft. Wellington: Pharmaceutical Society of New Zealand. https://www.nzma.org.nz/assets/Uploads/Documents/Framework.pdf
Picker Institute. (1987). Picker Principles of Patient-Centered Care. https://www.picker.org/about-us/picker-principles-of-person-centred-care/
Picton, C. (2015). The role of pharmacy in delivering person-centred care. London: Royal Pharmaceutical Society and National Voices. https://www.nationalvoices.org.uk/sites/default/files/public/publications/the_role_of_pharmacy_in_delivering_person-centred_care_-_rps_nv.pdf
Rapport, F., Doel, M., Hutchings, H., Wright, S., Wainwright, P., John, D., et al. (2010). Eleven themes of patient‐centred professionalism in community pharmacy: innovative approaches to consulting. International Journal of Pharmacy Practice, 18(5), 260-268. https//doi.org/10.1111/j.2042-7174.2010.00056.x
Redding, D., & Hutchinson, S. (2017). Person-centred care in 2017. London: National Voices. https://www.nationalvoices.org.uk/publications/our-publications/person-centred-care-2017
Robinson, J., Callister, L., Berry, J., & Dearing, K., A. (2008). Patient-centered care and adherence: definitions and applications to improve outcomes. Journal of the American Academy of Nurse Practitioners, 20(12), 600-607. https//doi.org/10.1111/j.1745-7599.2008.00360.x
Royal Pharmaceutical Society Wales. (2014). Your Care, Your Medicines: Pharmacy at the heart of patient-centred care. Wales: NHS Wales. https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Publications/Your%20Care%20Your%20Medicines%20report.pdf
Ryan, D., Grey, C., & Mischewski, B. (2019). Tofa Saili: A review of evidence about health equity for Pacific Peoples in New Zealand. Wellington; Pacific Perspectives Ltd. https://www.pacificperspectives.co.nz/_files/ugd/840a69_e60e351af88048ed8fa005ad28955f9a.pdf
Schön, D. (1983). The Reflective Practitioner: How professionals think in action. The Reflective Practitioner: How professionals think in action: Temple Smith.
Shaller, D. (2007). Patient-centered care: What does it take? New York: Commonwealth Fund. https://www.commonwealthfund.org/publications/fund-reports/2007/oct/patient-centered-care-what-does-it-take
Sharma, T., Bamford, M., & Dodman, D. (2015). Person-centred care: an overview of reviews. Contemporary Nurse, 51(2-3), 107-120. https//doi.org/10.1080/10376178.2016.1150192
Sumsion, J., & Goodfellow, J. (2004). Identifying Generic Skills through Curriculum Mapping: A Critical Evaluation. Higher Education Research & Development, 23(3), 329–346. https://doi.org/10.1080/0729436042000235436
Talemaitoga, A. (2010). The health of Pacific peoples in Aotearoa is “everybody’s business”. Best Practice Journal, 32, 5-9. https://bpac.org.nz/bpj/2010/november/docs/BPJ_32_upfront_pages_59.pdfhttps://bpac.org.nz/bpj/2010/november/docs/BPJ_32_upfront_pages_5-9.pdf
Tan, K. K. H., Ellis, S. J., Schmidt, J. M., Byrne, J. L., & Veale, J. F. (2020). Mental Health Inequities among Transgender People in Aotearoa New Zealand: Findings from the Counting Ourselves Survey. International Journal of Environmental Research and Public Health, 17(8), 2862. https//doi.org/10.3390/ijerph17082862
Te Karu, L., Bryant, L., Harwood, M., & Arroll, B. (2018). Achieving health equity in Aotearoa New Zealand: The contribution of medicines optimisation. Journal of Primary Health Care, 10(1), 11-15. https://doi.org/10.1071/HC17067
ten Cate, Th. J., Kusurkar, R. A., & Williams, G. C. (2011). How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE Guide No. 59. Medical Teacher, 33(12), 961-973. https//doi.org/10.3109/0142159X.2011.595435
Thomas, D. R. (2006). A General Inductive Approach for Analyzing Qualitative Evaluation Data. American Journal of Evaluation, 27(2), 237-246. https://doi.org/10.1177/1098214005283748
Te Tiriti o Waitangi [Māori version] (1840). https://www.flickr.com/photos/archivesnz/12195494103/in/album-72157640803885745/
Tsingos, C., Bosnic-Anticevich, S., & Smith, L. (2014). Reflective Practice and Its Implications for Pharmacy Education. American Journal of Pharmaceutical Education, 78(1), Article 18. https//doi.org/10.5688/ajpe78118
UNAIDS. (ND). An introduction to triangulation. Geneva, Switzerland: UNAIDS. https://www.unaids.org/sites/default/files/sub_landing/files/10_4-Intro-to-triangulation-MEF.pdf
University of Auckland. (2021). Bachelor of Pharmacy (BPharm). https://www.auckland.ac.nz/en/study/study-options/find-a-study-option/bachelor-of-pharmacy-bpharm.html
Wallman, A., Vaudan, C., & Sporrong, S. (2013). Communications training in pharmacy education 1995-2010. American Journal of Pharmaceutical Education, 77(2), Article 36. https//doi.org/10.5688/ajpe77236
Wepa, D., & Wilson, D. (2019). Struggling to be involved: An interprofessional approach to examine Māori Whānau engagement with healthcare services. Journal of Nursing Research and Practice, 3(3), 1-5. https//doi.org/10.37532/jnrp.2019.3(3).1-5
Wolters, M., van Hulten, R., Blom, L., & Bouvy, M. (2017). Exploring the concept of patient centred communication for the pharmacy practice. International Journal of Clinical Pharmacy, 39(6), 1145-1156. https//doi.org/10.1007/s11096-017-0508-5
World Health Organization. (2016). Framework on integrated, people-centred health services. Report by the Secretariat. Geneva: World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/252698/A69_39-en.pdf?sequence=1&isAllowed=y
