Article � December 2009, Vol. 1, No. 1 AJHPE Article Background Primary health care (PHC) is an equity-driven approach to health care1 that formed the foundation of South African national health policy under the new democratic government in 1994. In August 1994 the Faculty of Medicine (later renamed the Faculty of Health Sciences) at the University of Cape Town (UCT) adopted a policy on the PHC approach in order to equip its graduates with the values and skills necessary to meet the changing demands of the new national health system. This policy committed the Faculty to make the PHC approach central to its teaching, research, clinical service, and engagement with communities.2 The PHC Lead Theme: key principles and sub-themes The following key principles of the PHC approach have guided the PHC Directorate in leading the development of a cross-disciplinary PHC Lead Theme in transformed health sciences curricula for multi-professional learning:3,4 1. Promoting equity and human rights in health care. 2. Displaying bio-psychosocial and cultural sensitivity towards the pa- tient. 3. Practising health promotion at the individual and population level. 4. Promoting evidence-based health care. 5. Treating patients at the appropriate level of care. 6. Promoting multi-professional health care. 7. Promoting broad inter-sectoral collaboration. 8. Encouraging communities to assert their rights and interests. 9. Monitoring and evaluating the effectiveness, efficiency and equity of health services. The authors each carry primary responsibility from within the PHC Directorate for teaching and assessing principles 2 - 4 above, which are central to the PHC sub-themes of culture, psyche and illness (CPI); health promotion (HP); and evidence-based practice (EBP) in the 6-year medi- cal (MB ChB) curriculum. The first cohort of students under the trans- formed MB ChB curriculum graduated in December 2007. Culture, psyche and illness CPI encompasses the disciplines of psychology, psychiatry, social sci- ence, and medical anthropology. Cultural competence and the bio-psy- chosocial aspects of patient care are being integrated into medical educa- tion internationally,5 and are recognised as core competencies in South Africa, with its diversity of languages, cultures, customs, belief systems, and family structures. The culturally prescribed forms in which patterns of disease and illness symptoms present and are interpreted and treated add to this complexity. Biomedicine and traditional healing practices also have their own culturally prescribed forms of communication, behaviour and roles.6 Medical students are introduced to the social science and psycho- logical theory that underpins CPI by means of supported problem-based learning (PBL) group sessions in the first 3 years of their 6-year training. They discuss how the cultural, psychological and social context in the case scenarios affects the pattern of disease, while being encouraged to reflect on their own culture and the culture of biomedicine and the health system. Student learning about CPI is carried through to the clinical rotations in the latter half of the curriculum by means of teaching ward rounds. In the 4th-year general medicine ward round, for example, a medical an- thropologist (LV) joins the consulting physician and selects a number of appropriate cases for students to interview. Students then participate in a tutorial with LV to explore their insights into the bio-psychosocial history and cultural context of the selected patients. An annual multi-disciplinary portfolio-based exam is used to assess student knowledge about clinically relevant bio-psychosocial informa- tion, multi-professional teamwork and correct referral procedures, as well as testing skills in professional communication, and in anthropo- logical observation and analysis. Health promotion Students learn to apply behaviour change theories and HP approaches in patient consultations during the first 3 years of the curriculum. In the 4th- year public health rotation they are placed at different community-based learning (CBL) sites to assess public health problems identified by com- munity stakeholders and to plan and implement HP projects to address the prioritised health needs. These placements aim to develop awareness of the importance of community participation as a health right, the application of HP ethics, the planning cycle process, teamwork and critical reflection. Students learn skills in planning, organising, facilitation, presentation, and devel- oping and pre-testing mass media. It is anticipated that they will learn to use advocacy, mediation and enablement as long-term strategies in addressing the health needs of the patients and communities that they serve. Integrating the primary health care approach into a medical curriculum: a programme logic model James Irlam, BSc, BSc (Med) Hons, MPhil Mpoe Johannah Keikelame, RGN, BSocSci, MPhil Lauraine Vivian, BSc Hons, MSc, PhD Primary Health Care Directorate, Faculty of Health Sciences, University of Cape Town Corresponding author: James Irlam (James.Irlam@uct.ac.za) 9 December 2009, Vol. 1, No. 1 AJHPE Article Evidence-based practice EBP has been defined as the practice of integrating skills in retrieving, appraising, and applying valid research evidence with clinical expertise in making health care decisions in the best interests of patients.7 Wide variations in the use of clinically proven interventions, often to the detri- ment of patient care, highlight the many gaps between current research and clinical practice. Students are taught in their 4th-year public health rotation how to formulate focused clinical research questions and to critically appraise journal papers with regard to study validity and clinical applicability. This teaching builds on prior learning about epidemiological study design and the concepts of validity, bias and confounding. The critical appraisal ses- sions complement student work in undertaking a literature review and developing a research protocol for an epidemiological field survey at the CBL sites. Students are assessed on their ability to appraise a journal paper by means of a written exam at the end of the rotation. At the end of the 6th-year family medicine rotation, students are as- sessed on their ability to clearly communicate evidence about the ben- efits and risks of treatments to role-playing patients in a primary care consultation, and to reflect afterwards on their personal evidence-based learning needs. A programme logic model Programme logic models are tools used by programme managers and evaluators to clarify the structure and internal logic of programmes at Table I. A programme logic model for evaluating sub-themes of the PHC Lead Theme in the medical curriculum of the University of Cape Town Sub-theme Learning objectives Teaching and learning activities Learning outcomes Outcome indicators Methods CPI Understand cultural and Supported PBL Demonstrate cultural Portfolio tasks Student evaluation bio-psychosocial aspects of health and bio-psychosocial Understand Portfolio tasks competence Multi-disciplinary Student interviews complementary and portfolio (MDP) OSCE traditional health practices Medical ward round tutorials Demonstrate Review of portfolio Understand the role of observational skills tasks the multi- professional team Understand principles of equity Apply principles of Understand mechanisms for multi-professional appropriate referrals teamwork Apply principles of equity Make appropriate referrals HP Understand behaviour change Group projects Apply behaviour change Marks for group projects, Review of group theories and approaches Seminars theories and approaches assignments, and projects Understand the planning Reflective journals Develop and implement reflective journals Student evaluation cycle process Written assignments a health promotion Multi-disciplinary Interviews with project portfolio (MDP) OSCE course convenor, site facilitators, students, community stakeholders Structured observations of community- based learning EBP Formulate structured Class lectures Formulate a well- Marks for written clinical questions Structured office structured clinical exam and SOO Access current oral (SOO) exam question Marks on standard research evidence Self-reflection on SOO Search for the evidence test of EBP competence Critically appraise Appraise the validity validity of evidence of the evidence Understand the statistical, clinical, and public health significance of research results Article 10 December 2009, Vol. 1, No. 1 AJHPE various stages of their development. Table I presents a model to clarify the learning objectives for each of the sub-themes of CPI, HP, and EBP, as well as the teaching and learning activities used to deliver course con- tent, the short-term learning outcomes, the indicators for assessing stu- dent performance, and the methods to be used for data collection. This programme logic model will provide a useful framework for future monitoring and evaluation of the PHC sub-themes of CPI, HP, and EBP within the medical curriculum of the University of Cape Town. Ethics Committee approval: none required. Conflict of interest: none. References 1. World Health Organization. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6 - 12 September 1978. Geneva: WHO. http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf (accessed 1 September 2009). 2. UCT Faculty of Medicine. The primary health care approach and the University of Cape Town Medical School. www.primaryhealthcare.uct.ac.za (accessed 1 September 2009). 3. Mayers P, Alperstein M, Duncan M, Olckers L, Gibbs T. Not just another multi- professional course! Part 2: nuts and bolts of designing a transformed curriculum for multi-professional learning. Medical Teacher 2006; 28(2): 152-157. 4. Duncan M, Alperstein M, Mayers P, Olckers L, Gibbs T. Not just another multi- professional course! Part 1. Rationale for a transformative curriculum. Medical Teacher 2008; 28(1): 59-63. 5. Astin JA, Sierpina VS, Forys K, Clarridge B. Integration of the biopsychosocial model: Perspectives of medical students and residents. Academic Medicine 2008; 83(1): 28-36. 6. Boutin-Foster C, Foster JC, Konopasek L. Physician, know thyself: The profes- sional culture of medicine as a framework for teaching cultural competence. Academic Medicine 2008; 83(1): 106-111. 7. Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson WS. Evi- dence based medicine: what it is and what it isn’t. BMJ 1996; 312: 71-72.