Family Medicine and Primary Healthcare: The Past, Present and Future

As defined by the World Health Organisation in the conference held in Alma Ata, Kazakhstan, in 1978, "Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination" [...].


Background
As defined by the World Health Organisation in the conference held in Alma Ata, Kazakhstan, in 1978, "Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination" [1]. This definition marked a turning point in the concept of primary care, arguing for a shift from the traditional biomedical (diseasecentred) model, based on the treatment of single episodes of illness, to a bio-psycho-social (patient-centred) model centred on prevention, continuity of care, health communication and the direct role of patients in disease management [2][3][4]. From this perspective, the "patient-centred" model does not exhaust the role of the health professional, nor does it negate the "disease-centred" model, but rather combines the traditional pathway of diagnosis and treatment according to evidence-based medicine (EBM) with the anthropological and subjective meaning offered by the patient's perception of him/herself [5][6][7].
More than forty years after Alma Ata, this proposal continues to respond effectively to the challenge posed by epidemiological changes (the prevalence of chronic diseases), social changes (growth in health inequalities) and cultural changes (patients' demand for more information and autonomy) in an ever-evolving society, in which family medicine acts as a link between local and hospital health settings, patients and specialists and prevention and treatment. [8][9][10].
In this context, the digital revolution heralded by Information and Communication Technology (ICT) has also changed the doctor-patient relationship. Indeed, today's society enjoys advanced technologies related to artificial intelligence, cloud computing or IoT (Internet of Things); efficient information systems; and e-health, which are now considered promising tools and strategies to promote health and well-being for the whole population [11][12][13].
In particular, mobile health (m-health), defined as a public health practice supported by mobile devices, was widely used to ease the health burden during the COVID-19 pandemic [14,15]. In this regard, m-health tools have been used by General Practitioners (GPs) to monitor lifestyles adopted during isolation (i.e., monitoring physical activity and proper nutrition), to remotely guide self-medication practices wherever and whenever necessary by recording disease parameters, to monitor adherence to prescribed drug therapies and to share information and reports with patients and health professionals, thereby helping to support primary care at a time of high demand for care [14][15][16][17].
Nevertheless, while new digital systems have enabled citizens to self-manage, they have also affected the deviation of perceived risk from real risk, sometimes leading to inappropriate behaviour in both hospital and community settings [18][19][20][21][22][23]. Here, again, the role of primary care medicine, with general medicine, the continuity of care service and paediatrics at the forefront, has been decisive in guiding patients and citizens towards the adoption of correct behaviour and health choices. An example in point is the commitment to vaccine counselling at a time when the determinants of vaccine hesitancy have been exacerbated by the emergence of a newly synthesised vaccine (anti-SARS-CoV-2) or the workload assumed in order to cope with complex situations in extremely precarious conditions from an organisational point of view [24,25]. These factors are among the main causes of the transformation of the care needs to which the social and health services need to respond.
Today, family medicine is an academic and scientific discipline, with its own educational and research content, its own evidence base and a clinical speciality oriented towards primary care [26,27].
Addressing a target group of patients differentiated according to macro-areas of clinical and care needs and represented in the different phases of life (childhood, adulthood and old age), family medicine constitutes the most inclusive, fair and efficient approach to improve the physical and mental health of individuals, as well as the well-being of society from a One Health perspective [1][2][3][4]27].
The characteristics of patients, in fact, are extremely diverse and vary in relation to the different types of needs and interventions. On the one hand, healthy (or apparently healthy) individuals require proactive and personalised preventive action that includes the promotion of healthy lifestyles together with adherence to vaccination prophylaxis and cancer screening [28][29][30][31]. On the other hand, individuals with new-onset diseases require the guarantee of a timely response accompanied by ad hoc counselling, ranging from simple health information to direct management for basic problems up to the referral to specialist services [32,33].
In addition, the number of individuals with chronic diseases is steadily increasing, with a high prevalence (overweight, hypertension, dyslipidaemia, diabetes, COPD, etc.) who need to be taken care of on a continuous basis over time and during transitions between the various levels of care; lastly, there are individuals in fragile conditions (physical, mental, social or economic) and/or with compromised personal autonomy and/or with complex care needs requiring the coordination and cooperation of all the various players indicated for the specific situation [34][35][36].
Today, ongoing demographic and epidemiological transformations are revealing that the population is ageing substantially, with the consequent increase in the prevalence of chronic-degenerative pathologies, the widening of the social inequality gap and the increase in the variability in community health needs, which are aspects directly linked to the processes of globalisation [37]. Moreover, the global burden of disease has changed a great deal over the last thirty years, increasing the need to focus on the organisation of health services. In such a scenario, it is becoming increasingly evident that the hospital setting cannot only represent effective, efficient and appropriate responses to often very complex frameworks that, on the contrary, require multidisciplinary and inter-sectoral care in the medium to long term [38][39][40][41][42][43].
By focusing on the health of the entire community, family medicine, as the foundation of primary healthcare, thus involves aspects of the organisation of healthcare systems, with a conceptual model characterised by (i) the accessibility and equity of the services offered, (ii) the centrality of the population's needs; (iii) the "cost-effective" and appropriate use of technologies and services, (iv) the integration of the different levels of care (primary, secondary and tertiary) and (v) the involvement of the patient and the community in the care project [44,45].
However, despite the recognised importance of general practice in all areas of healthcare, a growing crisis threatens the stability and effectiveness of this vital component of the healthcare system, namely the notable shortage of General Practitioners. This shortage has serious implications for patient care and the overall health of communities. Consider that in 2020, the pivotal year of a pandemic that claimed millions of lives worldwide in the absence of a vaccine, only 20% of physicians in EU countries were GPs [46]. In this context, health promotion is called upon to characterise health policies not only with the objective of preventing the onset of pathological conditions but also to create a level of competence and capacity for control (empowerment) that maintains or improves health capital in the community.
This means it is increasingly urgent to strengthen and innovate the network of territorial social-health services and to devise new integration strategies, promoting the active participation of citizenship [47].
A Special Issue entitled "The 10th Anniversary of Healthcare-Family Medicine" was launched in Healthcare in December 2022 and is a collection of original data or international literature on the role played by family medicine in protecting and promoting the population's health. This Special Issue aims to publish scientific evidence on the following topics: primary care and continuity of care; new challenges in relation to emerging diseases; vaccination and screening; prescriptive appropriateness; combating antimicrobial resistance (AMR) and antimicrobial stewardship.
Several topics are addressed, and all manuscripts are published and available online in open-access form. They are listed in chronological order of publication in Table 1, along with the following information: the authorship (first author), topic, time of investigation, methodology, and main results of the study.    The growing medical shortage crisis in primary care is a significant threat to the stability and effectiveness of healthcare systems. Addressing this problem requires a multi-pronged approach encompassing various aspects, including medical education and collaboration between institutions.
Wang, Y.-Y. et al. [63] To examine the relationship between family health and college students' health literacy and the mediating role that psychological resilience plays in this relationship

Survey
Family health may be a potential key factor in improving college students' health literacy, whereas psychological resilience functions as a mediating mechanism.

Discussion
Numerous topics are addressed in the Special Issue entitled "The 10th Anniversary of Healthcare-Family Medicine". Some of the studies included investigated the knowledge, attitudes and behaviour of primary care physicians in relation to various aspects: practices of evidence-based medicine (EBM) among primary care physicians in Saudi Arabia [52]; the diagnostic and therapeutic management of Helicobacter pylori infection [56]; and pharmaceutical prescription errors in intensive care units [59] and palliative care education and training in Malaysia [60], particularly exploring the importance of the academic training of university students regarding the need to request diagnostic investigations in order to develop a reflexive approach regarding prescriptive appropriateness [49].
The role of clinical trials in the context of family medicine was examined in relation to the attitude of the general population towards compliant participation in studies of this type, aimed at improving public awareness of the importance of participating in clinical trials necessary for the development of new drugs [61]. Of particular interest were aspects related to the importance of family medicine in the management of psychological and emotional disorders; in particular, the following were examined: (i) the relationship between family background associated with Attention Deficit Hyperactivity Disorder (ADHD) symptoms [48] and mental health problems among students attending the psychological support clinic at their university [54], (ii) the mediating role that psychological resilience plays in the relationship between family health and health literacy among university students [63], (iii) the relationship between depressive symptoms and socio-demographic factors among fertile Jordanian and Palestinian couples [50], (iv) the possible relationship between depressive disorders and clinic (glycated haemoglobin levels) in elderly patients with diabetes [40] and (v) the burden of caregivers of people with dementia through stress detection instruments [53].
Two of the articles published in the Special Issue examined the impact of the COVID-19 pandemic on primary healthcare with regard to the support of domestic violence cases during the lockdown in Mexico [57] and the working conditions of primary care physicians who were faced with great difficulties in managing patients, whereby remote care was added to routine care, adding to the already overwhelming burden of primary care with limited human resources [55]. Other topics, such as the study of the relationship between sarcopenic obesity and auditory function [51], the administration of useful drugs to reduce weight in obese patients [58], the evaluation of the clinical management of specific dermatological conditions by primary care physicians [39] and the description of the shortage of GPs in relation to the need to enhance university training in primary healthcare [62], were also addressed in this Special Issue.
This Special Issue, "The 10th Anniversary of Healthcare-Family Medicine", aims to identify further best practices of proven effectiveness in the field for the implementation of problem-solving strategies to achieve health goals. Articles, systematic reviews, metaanalyses, short communications, short reports, letters or other types of articles dealing with the multidisciplinary nature of these topics and their impact on public health, also with reference to different population cohorts (infants, adolescents, adults, elderly and at-risk populations), are welcomed and encouraged to be submitted. Manuscripts may be submitted to this Special Issue by 31 October 2023.