Which educational interventions have been implemented to support clinical competencies among primary healthcare professionals? A scoping review

Abstract

Background

Strengthening clinical competence among primary health care (PHC) professionals is essential as they directly influence the quality of care provided to healthcare users. Clinical competence is a multidimensional construct that integrates knowledge, skills, attitudes, and professional judgment. Despite the recognized importance of education for professional competencies, evidence remains limited regarding the effects of educational interventions on clinical competence among PHC, including how these effects are measured and which clinical competencies are developed through such interventions. This scoping review aimed to map educational interventions targeting PHC professionals and to examine how clinical competence has been assessed within these initiatives.

Methods

This scoping review followed PRISMA-ScR guidelines. A comprehensive search was conducted in March 2025 in the databases PubMed, LILACS, PsycINFO, Embase, CINAHL, and Scopus, followed by an exploratory search on Google and the websites of recognized public health institutions to identify additional information, such as training programs and reports. Two independent reviewers evaluated the eligible sources and extracted information on the educational interventions using a standardized form developed by the authors.

Results

After screening 3,839 records, 91 information sources were included, of which 30 were peer-reviewed studies reporting evaluated outcomes. Most interventions addressed non-communicable chronic diseases, delivered through self-instructional online learning and classified as short non-degree courses. Among evaluated studies, improvements were predominantly observed in knowledge-based outcomes. Assessment approaches varied widely, with limited use of validated instruments and minimal direct evaluation of clinical performance. Several studies relied on practice-based proxy indicators or patient-level outcomes as indirect measures of competence.

Conclusion

Primary healthcare is a strategic setting for implementing educational interventions to strengthen clinical competence across diverse health conditions. Although most evaluated studies report improvements in knowledge, evidence regarding their impact on multidimensional clinical competence remains limited. Future research should prioritize validated assessment instruments and practice-based evaluation approaches to better capture changes in clinical performance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-026-03355-w.

Background

Continuing education consists of technical updates delivered through activities such as conferences and specialized courses [1]. In contrast, permanent education in health integrates learning, service delivery, and management, emphasizing critical reflection. According to the Brazilian Ministry of Health [2], permanent education takes place in the workplace, where teaching and learning are embedded in daily routines and professional practice [2, 3]. Together, continuing and permanent education contribute to the development of clinical competence, which is defined as the ability to integrate knowledge, skills, values, and attitudes to act with responsibility, ethics, and efficacy [4, 5]. The concept of clinical competence is multidimensional, reflecting the intricacies and complexities inherent in medical practice. This conceptual framework is grounded in Miller’s Pyramid, which organizes competence into progressive levels, from knowledge and competence to performance and action, and has been expanded to incorporate the dimension of professional identity [4].

Preliminary studies have shown that clinical abilities are positively associated with professional confidence and self-efficacy, while also reducing job burnout and enhancing patient safety and satisfaction [6, 7]. Strengthening these skills is therefore crucial, as they directly influence the quality of care provided to healthcare users [8]. In a constantly evolving healthcare environment, professionals must continuously update their knowledge and practices to meet the population’s changing needs. Demographic shifts and epidemiological transitions further underscore the importance of continuous learning and adaptation in the field [9, 10]. Consequently, healthcare practices must align with population needs and community expectations, while also supporting ongoing professional development [3, 11].

This approach is closely aligned with the principles of primary health care (PHC), which emphasize comprehensive, people-centred services across prevention, health promotion, treatment, rehabilitation, and palliative care [12]. PHC has been shown to reduce overall health care costs and increase efficiency by improving access to preventive and promotive services [13]. Moreover, the WHO estimates that scaling up PHC interventions across low- and middle-income countries could save 60 million lives and increase average life expectancy by 3.7 years by 2030 [14].

Despite the recognized importance of education for professional competencies, evidence remains limited regarding the effects of educational interventions on clinical competence among PHC professionals, including how these effects are measured and which clinical competencies are developed through such interventions. The few existing reviews on primary healthcare professionals and education have focused on team-based learning [15], nursing practices [16], online learning [17], or digital health competencies [18]. Therefore, to address these gaps, this review aims to map the current evidence on educational interventions (EIs) targeting PHC professionals and their outcomes in terms of clinical competence for clinical management.

Methods

This scoping review followed the recommendations of the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) and the JBI Manual for Evidence Synthesis [18, 19] and was conducted using an exploratory-descriptive analysis that proposed to qualitatively evaluate the results found in database of peer-reviewed literature and web-based sources (e.g. courses, training programs, reports, etc.) regarding the research question “Which educational interventions have been implemented to improve clinical competencies among primary healthcare professionals?”. The leading question followed the structure of the “PCC”, which corresponds to “Population” (P), “Concept” (C), and “Context” © [18]. The protocol is available at the Open Science Framework platform (10.17605/OSF.IO/5G3B4).

Search strategy

The search strategy followed three steps, as outlined in the JBI Manual for Evidence Synthesis [18]. The first step involved an initial search limited to two databases (MEDLINE and LILACS) using the PCC terms: “primary health care” (P), and “education” or “staff development” (C), and “disease management” (C). In the second step, terms used in the titles, abstracts, and index terms from the initial search were analyzed. The third step consisted of a more comprehensive search in both English and Portuguese using the keywords and index terms identified, across the databases PubMed, LILACS, PsycINFO, Embase, CINAHL, and Scopus. The search strategy was restricted to studies published in Portuguese and English to allow a full reading of the studies in their original languages, mitigating potential interpretative losses, inaccuracies, or insinuated context that can occur during the translation process. This step also included searching the reference lists of included studies to identify any studies not captured in the database searches. No temporal restriction was applied to peer-reviewed literature searches to comprehensively map the available scientific evidence on educational interventions targeting clinical competence in primary health care.

In addition, an exploratory search on Google and on websites of recognized public health institutions was conducted in April 2025 to identify educational initiatives not documented in peer-reviewed literature, such as courses and training programs. The Google search was conducted in both Portuguese and English, and performed independently by two reviewers (B.N.R. and A.E.K.), using Google Chrome in incognito mode to minimize personalization bias and avoid influence from previous browsing history. No geographic filters were applied. The following combinations of search terms were used: (“educational intervention” OR “course”) AND (“primary healthcare professional” OR “primary health care”), and their equivalent terms in Portuguese. Quotation marks and Boolean operators were applied to refine the searches. For each language, the first 200 results were screened, as search engine outputs generate a high volume of results with decreasing relevance beyond the initial pages. All links found were independently screened by two reviewers to determine eligibility. Disagreements were resolved through discussion.

Recognized institutions were defined as national or international governmental health agencies, public health organizations, universities, or professional associations involved in primary health care or health workforce development. When relevant institutional websites were identified, they were directly accessed and screened for eligible educational initiatives. The recognized institutions included the World Health Organization (WHO), the World Organization of Family Doctors (WONCA), the European Centre for Disease Prevention and Control (ECDC), the Pan American Health Organization (PAHO), the Open University of the Brazilian National Health System (UNA SUS), and the National Institutes of Health (NIH). The data presented were obtained in partnership with the Brazilian Ministry of Health through the Institutional Development Support Program of the Unified Health System (PROADI-SUS).

Data selection

Peer-reviewed literature

Data selection was performed independently by two reviewers (B.N.R. and A.E.K.) using the Rayyan platform (Systems Inc., 2025). Titles and abstracts were screened first, followed by full-text reading, based on the eligibility criteria. Studies were included if they: (i) involved an educational intervention, (ii) included primary healthcare professionals as the population, and (iii) assessed clinical competence as an outcome, regardless of study design, country, language, or year of publication. For peer-reviewed studies, no temporal restriction was applied to comprehensively map the scientific evidence on educational interventions targeting clinical competence in primary health care. Reviews of any type were excluded.

Web-based sources

For web-based sources, only educational interventions developed within the last 10 years were considered eligible. This criterion was adopted to limit the mapping to initiatives reflecting current educational practices and contemporary primary health care contexts, regardless of the country or format (in-person, online, or hybrid). For the Google search, the first 200 results in both Portuguese and English were screened, due to the large number of results.

Data extraction and analysis

Data extraction was performed independently by two reviewers (B.N.R. and A.E.K.) using a standardized form developed by the authors. For peer-reviewed literature, extracted information included study characteristics (authors, year of publication, country, aims, population, and sample size), assessment tools and their psychometric properties, key concepts or domains of clinical competence assessed, details of the educational interventions (aims, format, workload, and content), and the main outcomes relevant to the research question. Data extracted from web-based sources included the target audience, country and year, and key characteristics of the interventions, such as type, mode of delivery, workload, specific goals, program content, and type of assessment or exam. The supplementary file provides the detailed information extracted from each source.

The extracted data were analyzed qualitatively to map and synthesize the evidence, following the JBI scoping review methodology, with a focus on the outcomes of educational interventions on the clinical competence of primary healthcare professionals, as well as on the types, workload, and assessment methods of the interventions. Educational interventions were classified by workload as follows: short courses (< 30 h), continuing education courses (> 30 h), continuing professional development courses (> 160 h), advanced training courses (> 180 h), and postgraduate specialization courses (> 360 h) [20].

Results

Study selection and source characteristics

A total of 3,954 records were identified through database and web-based searches. After screening and eligibility assessment, 91 sources were included in this review (Fig. 1). Of these, 30 were peer-reviewed studies reporting evaluated outcomes, while 61 were web-based educational initiatives (courses, training programs, institutional reports) primarily described without formal assessment of effectiveness. Figure 1 shows the flowchart, and the Supplementary Files present the main characteristics of the included sources.

Fig. 1.

PRISMA Flowchart describing the included sources of information

Descriptive mapping of educational interventions (n = 91)

This section presents the overall landscape of educational initiatives identified, regardless of whether formal outcomes were evaluated.

Health conditions and subjects covered by EIs

The EIs identified in this review addressed a broad range of 31 different health conditions, reflecting the diverse demands of primary healthcare practice. Most interventions focused on noncommunicable diseases (NCDs) (n = 42; 43.7%), followed by those related to infectious diseases (n = 7; 7.3%), pain management (n = 7; 7.3%), and mental health (n = 7; 7.3%).

NCD-related initiatives

Two sources targeted NCDs in general, while others addressed specific conditions, most frequently obesity or overweight (n = 9), diabetes mellitus (n = 9) and systemic arterial hypertension (n = 6). EIs on overweight and obesity aimed to develop primary healthcare professionals’ knowledge, skills, and attitudes to address these conditions as multifactorial health issues. Key components included patient-centred perspectives, case discussions, updates in pharmacotherapy, and decision-making strategies. The interventions also emphasized promoting healthy eating habits, integrating preventive actions into primary care workflows, and providing age-appropriate care for children and adolescents diagnosed with overweight or obesity. On hypertension and diabetes, the main topics covered are epidemiology, pathophysiology, risk factors, diagnosis, classification, risk stratification, lifestyle counselling, pharmacological management and adherence, management of complications and comorbidities, care of special populations, and multidisciplinary approaches. Specific content also addressed accurate blood pressure measurement, renal causes of secondary hypertension, COVID-19 considerations, glycemic control, diabetic foot care, hypoglycemia management, and adherence to diabetes guidelines.

There was a focus on developing healthcare professionals’ skills in the clinical management of respiratory diseases, particularly COPD (n = 3) and asthma (n = 3). They covered epidemiology, signs and symptoms, differential diagnosis, severity assessment, and appropriate referrals. Training included both pharmacological and non-pharmacological interventions, environmental control, vaccination, smoking cessation, and patient education. Participants learned to support self-management, optimize medication use, instruct on inhaler techniques, and implement exercise and oxygen therapy when needed, as well as provide care in resource-limited settings. Chronic kidney (n = 2) and liver (n = 1) courses also focused on the pathophysiology, prevention, diagnosis, and management of these conditions, supported by case studies and practical applications. Liver-related content addressed abnormal liver function tests, hepatitis C, non-alcoholic fatty liver disease, cirrhosis, and its complications.

Infectious diseases

There were courses on tuberculosis (TB) (n = 4), covering its epidemiology, microbiology, clinical presentation, laboratory and radiologic diagnosis, monitoring and evaluation. Participants learned about prevention and infection control, drug-sensitive and drug-resistant TB management, TB-HIV co-infection, and pediatric TB. Emphasis was also placed on health equity, including the impact of racism on TB care, and on evidence-based strategies for effective treatment, follow-up, and public health management. COVID-19 modules (n = 2) explored the epidemiological situation in Africa and the United Kingdom, recognition of suspected cases, clinical evaluation, and management of both acute and home-isolated patients.

Pain management

Courses on pain management (n = 7) aimed at improving understanding pain mechanisms and improving clinical and assessment approaches for both acute and chronic pain in primary care. The conditions covered included headache, abdominal pain, otitis, pharyngitis, low back pain, chest pain, and neuropathic pain.

Mental health

Topics on depression (n = 4) included pharmacotherapy, antidepressant dosages and side effects, patient education, referral criteria, and the importance of follow-up and continued care. It was also incorporated case discussions and the use of WHO’s Mental Health Gap Action Programme (mhGAP) to support the identification, treatment, and monitoring of mental health disorders, including self-harm and suicide prevention.

The courses on dementia (n = 3) focused on timely diagnosis, management strategies, and the role of primary care in supporting patients and families, including concepts on dementia subtypes and risk factors, use of cognitive screening tools, evidence-based prescribing, collaboration with specialists, and the nurse’s role in assessment and ongoing care.

Training on substance dependence (n = 2) focused on identifying and managing risky alcohol and tobacco use in primary care. Participants learned to apply screening and brief intervention strategies (SBIRT), counsel patients based on national alcohol guidelines, and promote awareness within clinical settings. Training also sought to enhance understanding of the health, social, and economic consequences of tobacco use, the physical, psychological, and social aspects of dependence, and practical approaches to smoking cessation using the 5As and 5Rs models.

Vector-borne and other communicable diseases

These aimed to update healthcare professionals on the diagnosis, treatment, prevention, and control of dengue (n = 3), Chagas disease (n = 2), malaria (n = 3), and Zika (n = 3). Training combined theoretical and practical approaches, emphasizing case-based learning and current national guidelines.

The courses also provided healthcare professionals with foundational knowledge on HIV and other sexually transmitted infections (n = 4), including syphilis and viral hepatitis, covering opportunistic infections, current guidelines, and strategies for screening and testing high-risk populations, equipping professionals to deliver evidence-based, comprehensive sexual health care.

Other topics such as immunization (n = 4) were identified, along with a variety of other health issues (n = 18). The courses provided healthcare professionals with updated knowledge on vaccine logistics, storage, administration, and public health benefits. Content included immunization programs, technical protocols, strategies to address vaccine hesitancy, and guidance on vaccines such as Hepatitis A and B, Polio, Diphtheria, Tetanus, Pertussis, Yellow Fever, Measles, Mumps, Rubella, Varicella, Pneumococcal disease, Rotavirus, HPV, and COVID-19.

Geographic Distribution

The EIs identified in this review were implemented across multiple regions worldwide, highlighting the global importance of enhancing clinical competence in primary healthcare. The majority originated from Brazil (n = 34; 37.4%), followed by Australia (n = 14; 15.4%) and the United States (n = 11; 12.1%). Other initiatives were distributed across Europe (n = 7), South America (n = 6), and other regions (n = 19).

Brazil demonstrated notable institutional diversity, particularly through UNA-SUS and other public health institutions. This distribution reflects the availability and visibility of structured educational initiatives in certain contexts. More information is available in the Supplementary Files.

Targeted healthcare professionals, format, and workload

Most of the EIs were delivered to PHC professionals in general (n = 38), while some specifically targeted nurses (n = 7), physicians (n = 7), or both groups (n = 5). Distance learning was the most common format (n = 61; 67%), and, among these, the majority were self-instructional asynchronous courses (n = 52; 57%), while a smaller portion used synchronous formats (n = 9; 10%). In-person interventions were less frequent (n = 22; 24.2%) and were mostly identified through peer-reviewed studies.

The greatest variation in workload among the interventions was found in the self-instruction distance learning format, ranging from 30 min to 100 h, with an average of 20 h. The interventions offered in the synchronous distance learning format had a shorter duration, ranging from 1 to 64 h, with an average of 10 h. When classified by workload, the majority of interventions were short-term non-degree courses (< 30 h) (n = 56; 61.5%). No interventions were identified that met the criteria for continuing education courses (> 160 h), advanced training (> 180 h), or postgraduate specialization (> 360 h). It is important to note that workload reflects duration but does not necessarily indicate educational intensity or effectiveness.

Educational interventions with evaluated outcomes (Peer-Reviewed Studies, n = 30)

This section focuses exclusively on interventions that formally assessed outcomes related to clinical competence.

Competence domains assessed

The assessment approaches varied across studies. Eleven studies evaluated theoretical knowledge through tests, quizzes, or questionnaires. Ten studies employed practice-based measures, including medical record review, referral rates, prescribing patterns, vaccination coverage, and direct observation. Five studies assessed self-perceived competence or confidence using self-administered instruments. Two studies combined theoretical and practical measures. Two studies did not report detailed information on assessment methods.

Most assessments focused on knowledge acquisition. Direct evaluation of clinical performance through structured observation was reported in one study, as shown in Table 1.

Table 1.

Assessment tools used to evaluate the outcomes of educational interventions, competencies assessed, and target population

Authors	Year	Target population	Assessment approach	Valid or reliable instrument	Domain assessed
Gutiérrez, G. et al	1994	Family physicians	Prescription practices before and after the workshop	NI	Practice-based proxy indicator
Guiscafre, H. et al	1995	Family physicians	Questionnaires and electronic medical records	NI	Knowledge + Practice-based indicator
Bojalil R. et al	1999	Physicians	Direct observation using WHO/PAHO manual	Yes	Direct observation of clinical practice
Tiemens, B.G. et al	1999	Physicians	Outcomes of all patients with depression were measured at 3 months and 1 year	NI	Patient-level outcome
Lin, E.H.B. et al	2001	Physicians	Computerized visit and pharmaceutical data to evaluate how professionals diagnose patients	NI	Practice-based proxy indicator
Valentini W. et al	2004	Physicians	Pre- and post-test with patient self-assessment scale (Zung Depression Scale)	No	Knowledge + Patient-level outcome
Fernandes P.T. et al	2007	Physicians and Community Health Workers	Questionnaire assessing knowledge, attitudes, and perceptions (KAP)	Yes	Knowledge (theoretical)
VanSickle D. et al	2010	Nurses	Proportion of patients with documented blood pressure	NI	Practice-based proxy indicator
Masi C. et al	2012	Physicians	Carter’s 26-item questionnaire and a 7-item hypertension management questionnaire (adapted from Arora) for patient self-assessment of knowledge on hypertension management	Yes	Knowledge (theoretical)
Castro M.R.J. et al	2013	Nurses	Not reported	NI	Not informed
Lunay O. et al	2014	Reference physician Reference nurse FATC team	Proportion of subjects receiving at least one dose (vaccination acceptability) and proportion of subjects with two doses (vaccination coverage)	NI	Practice-based proxy indicator
Pimenta H.B., Caldeira A.P., Mamede S	2014	Physicians	Interviews with patients before and after, along with a review of medical records and indicators of: (i) any positive changes in hypertension treatment routines, (ii) improvement in medication prescribing, and (iii) use of medications that reduce the risk of cardiovascular disease	No	Knowledge + Practice-based indicator
Salcedo, R.M	2015	Physicians and Nurses	Formative and summative assessment	Yes	Knowledge (theoretical)
Gomes L.M.X. et al	2016	Community health workers and nursing technicians	25-item questionnaire adapted from a previous study conducted in the same region, divided into three sections: epidemiology, clinical manifestations, and management of individuals with sickle cell disease	Yes	Knowledge (theoretical)
Braschinsky M. et al	2016	Physicians	The percentage of patients referred to other levels of care. The primary analysis was the change in referral rate (RR) after the intervention and patient health outcomes	NI	Practice-based proxy indicator
Braschinsky M. et al	2017	Physicians	The primary outcome measure was the referral rate (RR) to neurological services; the secondary measure was the request for investigations (tests and X-rays)	NI	Practice-based proxy indicator
Barbosa M.C., Mattos E.B.T., Mendes R	2019	Community health workers (CHW)	Semi-structured questionnaire including: sociodemographic data, open-ended questions about the CHW’s role in the PHC unit, demand from older adults in the area, and level of understanding about dementia syndromes	No	Knowledge (theoretical)
Agreli H.F. et al	2019	Family Health Team professionals	Self-administered questionnaire with a 10-item test on knowledge of the Ministry of Health's recommendations for managing NCDs in PHC, developed by the authors in collaboration with specialists	No	Knowledge (theoretical)
Alcântara E.C. et al	2019	Family Health Team professionals	Knowledge questionnaire on Chronic Obstructive Pulmonary Disease in Primary Health Care (QAP-COPD)	Yes	Knowledge (theoretical)
Noble R.A. et al	2019	Physicians and Nurses	Pre- and post-test and participant feedback evaluating knowledge and confidence scale	No	Knowledge + Self-reported confidence
Braun L.W. et al	2020	Dentists	Likert scales to assess lesion frequency, experience in detection, number of continuing education activities on oral cancer, and self-efficacy in diagnosis and treatment	No	Self-reported competence
Paniagua-Avila A. et al	2020	Physicians, nurses, and nursing assistants	Difference in the proportion of participants with controlled hypertension between the intervention group (IG) and the control group (CG)		Patient-level outcome
Bogers, S.J et al	2021	Physicians	Self-perception questionnaire		Self-reported competence
Antunes M.D., Schmitt A.C.B, Marques A.P	2022	PHC professionals	Interviews with participants focused on the primary outcome of patients' quality of life	No	Patient-level outcome
Harris, P. et al	2022	Physicians	Pre- and post-test quizzes	No	Knowledge (theoretical)
Bhatt, N. et al	2022	PHC professionals	Pre- and post-questionnaires	No	Knowledge (theoretical)
Senna, J.P.N., Bedetti, A.D., Savassi, L.C.M	2022	PHC professionals	Not reported	NI	Not informed
Lindner S.R. et al	2023	PHC professionals	Assessment activities, consisting of multiple-choice questions for content reinforcement and an activity diary (a written assignment integrating theoretical content with practical experience)	NI	Knowledge + Reflective practice
Lindner S.R. et al	2024	Nurses	Assessment matrix for specialization and self-instructional courses	Yes	Knowledge + Practice-based assessment
Arini M. et al	2024	PHC professionals	Pre- and post-test with a true-or-false questionnaire	Yes	Knowledge (theoretical)

PHC Primary health care, FACT Free and anonymous HIV and hepatitis B/C testing centre, NI Not informed in the original study, Practice-based proxy indicators refer to indirect measures of professional performance (e.g., referral rates, prescribing patterns, documentation rates); Patient-level outcomes refer to clinical indicators measured at the patient level (e.g., blood pressure control, vaccination coverage, quality of life)

Assessment instruments and psychometric properties

Eight studies reported the use of validated or reproducible instruments. Three applied previously validated questionnaires [21–23], and three conducted content validation procedures with experts [24–26]. One study used structured observation based on the WHO/PAHO Diarrhea Case Management Manual [27], and one employed an evaluation matrix for specialization and self-instructional courses [28]. The remaining studies did not report information regarding instrument validity or reliability (Table 1).

Reported effects of educational interventions

Among the 30 evaluated studies, most reported improvements in knowledge related to disease management, guideline adherence, or clinical decision-making. Several studies reported changes in clinical practice indicators, including prescribing practices, referral rates, vaccination coverage, and hypertension control. In some cases, reductions in unnecessary specialist referrals were observed. Two studies reported no significant differences in knowledge or management outcomes following the intervention.

Across all included sources, educational initiatives in PHC were predominantly short-term and delivered through asynchronous distance learning formats. Among studies reporting evaluated outcomes, improvements were most frequently observed in knowledge-based measures. The use of validated assessment instruments was limited, and direct observation of clinical performance was infrequently reported.

Discussion

This scoping review aimed to map and analyze evidence on educational interventions for primary healthcare professionals and their effects on clinical competencies for managing health conditions. The findings indicate a broad landscape of educational activities across multiple health conditions, with substantial heterogeneity in delivery formats, workload, target populations, and outcome assessment approaches.

A total of 91 initiatives were identified, of which 30 peer-reviewed studies reported evaluated outcomes. The remaining 61 web-based sources primarily described courses and training programs without a formal assessment of effectiveness. This distinction is relevant, as it reflects the difference between mapping the educational landscape and evaluating the impact of interventions on clinical competence.

A key finding of this review was the significant emphasis on EIs addressing NCDs. Of the 91 EIs identified, nearly half (n = 42) targeted at least one NCD, such as hypertension, DM, obesity, or overweight. This distribution aligns with the epidemiological profile of PHC settings globally, where chronic conditions represent a significant burden. NCDs represent a major public health concern and are a central focus of the Sustainable Development Goals [9], as they accounted for at least 43 million deaths in 2021, equivalent to 75% of all non-pandemic-related deaths, with high rates of premature mortality occurring before the age of 70 [14]. Moreover, 82% of premature deaths were reported in low- and middle-income countries. In this context, it is reasonable that, among the 42 EIs addressing NCDs, 16 originated from Brazil or other South American countries. Brazil faces an epidemiological scenario marked by the predominance of chronic conditions, particularly hypertension and DM. In 2017, approximately three out of four deaths in the country were attributed to NCDs, underscoring the need for sustained and systematic actions to ensure adequate management and prevent related complications [29]. From this perspective, EIs emerge as relevant strategies to strengthen professional competencies and contribute to tackling this major public health concern. Brazil accounted for the largest proportion of identified initiatives. This predominance may be associated with the availability of structured public educational platforms, such as UNA-SUS (https://www.unasus.gov.br/), as well as the language criteria adopted in this review.

Distance learning, especially asynchronous self-instructional formats, was the most common delivery modality, a finding that is supported by previous studies. A scoping review identified that e-learning strategies offer valuable tools to enhance the quality of collaborative learning in PHC, including online case studies, interactive menus, and video clips, in addition to generally providing flexibility that makes them more convenient in the PHC setting [16]. On the other hand, a systematic review investigating in-person interprofessional education in PHC highlighted the development of teamwork, trust, and perceived clinical competence as its main outcomes [30]. Moreover, most interventions were short-term (< 30 h). Although workload classification allowed for standardized description, duration alone does not indicate educational intensity, methodological quality, or impact. Educational effectiveness depends on multiple factors, including instructional design, learner engagement, feedback mechanisms, and opportunities for practical application [19].

A central finding of this review concerns the operationalization of clinical competence. Although competence was conceptually defined as a multidimensional construct integrating knowledge, skills, attitudes, and professional responsibility, most evaluated interventions assessed knowledge acquisition through theoretical instruments [20–35]. Practice-based measures, such as referral rates, prescribing patterns, or medical record review, were less frequent [36–43]. Direct observation of clinical performance in situ was reported in only one study [44]. However, the theoretical definition involves a multidimensional construct which integrates knowledge, skills, values, and attitudes [4], the results illustrate educational interventions that focus only on the development of clinical knowledge. Therefore, when interpreted in light of Miller’s framework, these outcomes predominantly reflect the “knows” level of competence, with very limited evidence targeting higher levels such as “shows how” or “does,” which correspond to observable clinical performance [4]. This discrepancy highlights a gap between the theoretical definition of competence and its measurement in the literature. Knowledge improvement does not necessarily translate into changes in clinical performance or professional behaviour [45]. Furthermore, indirect indicators, such as vaccination coverage or referral rates, may reflect multiple contextual factors beyond individual competence.

Although most interventions were designed for all members of PHC teams, covering a range of health professional workers, the peer-reviewed manuscripts primarily focused on strategies for physicians and nurses. This is likely because family doctors/general practitioners are the professionals most consistently present in PHC across countries with this level of care, often serving as the population’s first point of contact, while nurses are also widely represented in PHC settings worldwide [32]. However, it is important that all PHC professionals continuously develop and strengthen their clinical competencies, since health care delivery is a shared responsibility [33–35]. Thus, continuous training and professional development can contribute to improved access, quality, and equity in healthcare, while also optimizing the use of health resources [35].

This review has limitations. The restriction to English and Portuguese may have limited the identification of initiatives from other regions and contributed to the predominance of Brazilian sources. The inclusion of web-based institutional sources broadened the scope of the mapping, but also introduced heterogeneity. These sources are not peer-reviewed and frequently lack outcome data. Their inclusion is consistent with scoping review methodology, which aims to map available evidence [46]. However, findings derived from descriptive sources should not be interpreted as evidence of effectiveness. Moreover, within the peer-reviewed studies evaluating clinical competencies, information regarding the instruments used to assess them was also scarce. Since clinical competencies comprise both theoretical constructs (knowledge) and practical elements (skills and attitudes), fully capturing them with purely theoretical instruments is challenging [4, 36]. This underscores the importance of validating assessment instruments to establish how accurately they capture practical constructs through theoretical measures [37].

Despite these limitations, this review provides a comprehensive overview of educational initiatives in PHC and highlights important gaps in the assessment of clinical competence. The findings suggest that while educational interventions are widely implemented, particularly in short-term and distance-learning formats, there is limited evidence regarding their impact on multidimensional clinical competence. Future studies should prioritize the development and use of validated instruments and incorporate practice-based and longitudinal assessment approaches to better capture changes in clinical performance.

In conclusion, PHC could be a key setting for the implementation of educational interventions, particularly those aimed at developing clinical competencies for the management of a wide range of health conditions. The mapping conducted in this scoping review indicates that the majority of interventions are implemented through short-term and distance learning formats, with a focus on noncommunicable diseases and specifically targeting physicians and nurses. Although most evaluated studies report improvements in knowledge, assessment of clinical competence remains predominantly theoretical and rarely incorporates validated instruments or direct evaluation of clinical practice. These findings highlight the need for more robust and multidimensional assessment approaches to better understand the impact of educational initiatives on clinical performance in primary health care.

Abbreviations

WHO

World Health Organization

WONCA

World Organization of Family Doctors

ECDC

European Centre for Disease Prevention and Control

PAHO

Pan American Health Organization

NIH

U.S. National Institutes of Health

UNA-SUS

Open University of the Brazilian National Health System

CONASS

National Council of Health Secretaries

CONASEMS

National Council of Municipal Health Secretaries

UFSC

Federal University of Santa Catarina

PRISMA-ScR

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

MEDLINE

National Library of Medicine

LILACS

Latin American and Caribbean Health Sciences Literature

CINAHL

Cumulative Index of Nursing and Allied Health Literature

JBI

Joanna Briggs Institute

PHC

Primary Health Care

NCD

Noncommunicable Disease

COPD

Chronic Obstructive Pulmonary Disease

TB

Tuberculosis

HIV

Human Immunodeficiency Virus

DM

Diabetes Mellitus

mhGAP

Mental Health Gap Action Programme

SBIRT

Screening, Brief Intervention, and Referral to Treatment

EI

Educational Interventions

Authors’ contributions

BNR: conception; design of the work; acquisition, analysis, and interpretation of data; draft. AEK: acquisition, analysis, and interpretation of data; draft. MPR: interpretation of data; draft. ALN: conception; review. NSG: review. LVH: conception; design of the work; review.

Funding

This study was supported by the Brazilian Ministry of Health through the Program to Support the Institutional Development of the Unified Health System (PROADI-SUS). The funding body had no role in the design of the study, data collection, analysis, interpretation of data, or in writing the manuscript.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.