Abstract
Background The global ecological crisis is impacting vulnerable African communities and their primary care services. Family physicians and primary care providers need to be better prepared to respond to the effects on services and communities.
Aim To evaluate what members of the Primary Care and Family Medicine (PRIMAFAMED) network in sub-Saharan Africa need to know about planetary health, and how to address their learning needs.
Design & setting A descriptive cross-sectional survey of 40 institutions in the PRIMAFAMED network.
Method Two members from each institution were purposively invited to complete a questionnaire, developed from a qualitative study.
Results Eighty responders came from 38 institutions and 24 countries. The majority were not familiar with planetary health (58.2%) and never attended related education (60.8%). Main barriers were lack of clinical relevance, institutional or government support, and educational resources. The top five clinical topics were: respiratory problems; infectious diseases; gastroenteritis; malnutrition; and cardiovascular disease together with diabetes. The top five broader topics were: how climate change impacts health; addressing environmental determinants through community-orientated primary care; how to make services more climate resilient and environmentally sustainable; and the effects of heat. Responders reported that videos (49.4%), PowerPoint (48.1%), links to expert speakers (36.7%), and continuing professional development (CPD) articles (35.4%) would be most useful.
Conclusion Family physicians are interested in CPD on planetary health. Educational resources should enable clinical CPD to integrate specific information and should also include broader planetary health topics. These resources will be developed within the context of the PRIMAFAMED network.
How this fits in
Planetary health is emerging as an important topic in health professions education. Several guidelines address formal curricula, mostly in high-income countries. Little is known about the continuing professional development needs of family doctors and primary care providers in sub-Saharan Africa. This study identifies these learning needs and how best to address them.
Background
Climate change is one of several interconnected ecological crises affecting our planet. Others include loss of biodiversity, changes in land use, and pollution. These ecological drivers interact with the health system in three different ways.1
Firstly, they have health and social effects across the spectrum of infectious diseases, non-communicable diseases, malnutrition, trauma, as well as mental health (Figure 1).2 Secondly, the same ecological drivers and proximate causes affect health infrastructure and ability to offer services.3 The World Health Organization has recognised the need to build climate-resilient health systems and facilities.4 Climate-resilient health care can anticipate, respond to, and recover from climate-related health risks.5 Lastly, is the historical contribution of the health system to the problem.6 The contribution of the health sector in Africa is not quantified, but is likely to be relatively small, as the whole continent only contributes 4% to global emissions.7 Nevertheless, African health systems need to develop with a low carbon trajectory.
The figure is a left-to-right conceptual framework of planetary health. Four linked stages are shown as colour-coded columns, connected by arrows to indicate progression from environmental change to human and social outcomes.The first stage, labelled “Ecological crisis”, lists climate change, global pollution, biodiversity loss, land use change, and altered biogeochemical cycles. An arrow leads to the second stage, labelled “Proximal causes”, which lists air quality, food production, infectious disease exposure, access to fresh water, and natural hazards. A second arrow leads to the third stage, labelled “Mediating factors”, which lists health system, governance, wealth, technology, and culture and behaviour. These factors can mediate the impact of the proximal causes on the health and social effects. A final arrow leads to the fourth stage, labelled “Health and social effects”, which lists malnutrition, infectious diseases, non-communicable diseases, injuries and trauma, mental health, and displacement and conflict.
Primary health care has a critical role as a mediating factor between the ecological drivers and health or social effects.8, 9 As a ‘whole of society’ approach to improving health and wellness it can reduce the impact of proximate causes, such as changes in food production and water quality.10 Community empowerment and multisectoral collaboration are essential ingredients. It is also the most accessible and responsive part of the health system to the health needs of the community.
Therefore, primary health care has the potential to increase the climate resilience of communities, but to do this must also be resilient and of high quality.11 A recent scoping review on primary health care and climate change in Africa identified the learning needs of the primary care workforce as a key research question.11 Family doctors were unsure of their role and lacked confidence in how to address climate change. Despite this they were seen as potential advocates with policymakers and important actors in building climate resilience in their communities.
The PRIMAFAMED network (an institutional network of departments of family medicine and primary care in sub-Saharan Africa) held a workshop on their climate-related educational needs in 2023 and identified continuing professional development (CPD) as a priority. Following this, a qualitative study explored the key CPD issues with key informants in the PRIMAFAMED network.12 This study continues by quantifying these themes in a descriptive survey. The aim was to evaluate what members of the PRIMAFAMED network need to know about planetary health and how their learning needs should be addressed through CPD.
Method
Study design
This was a cross-sectional descriptive survey as the second phase of an exploratory sequential mixed methods study. The first qualitative phase was published elsewhere.12 The themes identified in the first phase informed the design of the questionnaire in this study.
Conceptual framework
Planetary health is ‘a solutions-oriented, transdisciplinary field and social movement focused on analyzing and addressing the impacts of human disruptions to Earth’s natural systems on human health and all life on Earth.’13 Our model of planetary health is shown in Figure 1 where multiple ecological drivers have common proximate causes for their health and social effects.14 The magnitude of these effects will depend on mediators such as the wealth of the country, strength of the health system, access to technology, and governance.2
In our study we focused on learning needs regarding the health and social effects from a family medicine and primary care perspective and with some attention to the health system as a mediating factor and understanding of the proximate causes. We did not evaluate knowledge of the ecological drivers and most participants were more familiar with the concept of climate change.12
Study setting
The PRIMAFAMED network includes 25 countries and 40 institutions.15 Although these departments are mostly within the discipline of family medicine, they are also involved in teaching clinical officers and nurse practitioners. The members of these departments work in primary care teams and primary hospitals and teach both undergraduate and postgraduate students on family medicine and primary care. Therefore, the members of the network are well positioned to understand their primary care and educational contexts.
Study population, sample size, and sampling
All 40 institutions in PRIMAFAMED were included in the survey, with two responders purposively selected from each department, giving an intended sample size of 80. The survey targeted the head of department or a senior academic and one more junior family physician or practitioner. Participants were identified from the PRIMAFAMED listserv because they had been active and engaged within the network.
Data collection
A questionnaire (Supplementary Form 1) was designed to quantify the learning needs and educational approaches from phase 1.12 Phase 1 identified six broad learning needs, specific clinical topics, and information about the preferred methods of CPD. Learning needs could also be extrapolated from the themes on health and social effects related to climate change, emergency preparedness, disruption of routine services, and ideas on climate resilience of facilities and services. The questionnaire also included demographic data to describe the responders. A few items were added from the literature to test if these were important.16 The questionnaire was developed in English, the usual language of communication in PRIMAFAMED. It was also translated into French, as several countries are French-speaking.
The questionnaire was content validated by a panel of eight experts derived from the World Organization of Family Doctors (WONCA) Working Group on Planetary Health, the Southern African Association of Health Educators (SAAHE) and members of PRIMAFAMED who participated in a preparatory workshop for this study in 2023. An iterative process considered the relevance and phrasing of each item and any missing items. Once the questionnaire was revised, it was piloted by the PRIMAFAMED executive. This ensured that the items were understandable, had face validity, and could be administered easily via REDCap (Research Electronic Data Capture).
An invitation to complete the questionnaire was sent via email in March-April 2025 from REDCap. Reminders were sent on a weekly basis and where there was no response another person was purposively identified from that institution or country. Data collection continued until the desired sample size was achieved.
Data analysis
Data were exported from REDCap to the Statistical Package for Social Sciences (SPSS) and analysed. Analysis was descriptive and categorical data are reported as frequencies and percentages, while numerical data are reported as means and standard deviations, or medians and interquartile ranges, depending on the distribution.
Results
Responder characteristics
There was a total of 80 responders with a mean age of 47.9 (standard deviation [SD] 10.0) years and 62% (n = 49) were male. Table 1 presents the characteristics of responders. The majority were family physicians (86.1%), had a mean 15.9 (SD 10.2) years of experience, worked at universities (51.2%) and provided clinical services in primary care, primary hospitals, or tertiary hospitals. The majority worked in the public sector (72.5%) but 50.0% had some involvement with the private sector. The responders came from 24 countries within the PRIMAFAMED network (Table 2) and included 38 institutions.
Continuing professional development activities
Table 3 presents the types of CPD activities and resources. Almost all responders were comfortable with CPD in English (n = 71, 89.9%), with 5 (6.3%) preferring French and 3 (3.8%) Portuguese. The most important CPD activities were in-person talks, conferences, webinars, journal articles, and journal clubs. Responders also mentioned workplace-based clinical training, peer reviewing, and writing journal articles as other forms of CPD. When accessing online CPD, 72.2% (n = 57) used a laptop and 27.8% (n = 22) a smartphone.
The main incentives to attend CPD were that it was a national requirement, enabled networking and new connections, or provided a certificate. Other incentives mentioned by responders included the relevance and educational value of the topic, support for promotion, and an acceptable venue with good Wi-Fi.
Responders reported that open-access video materials (49.4%) and PowerPoint slides (48.1%) would be the most useful CPD resources. In addition, links to expert speakers who were willing to assist (36.7%) and the provision of journal articles with CPD quiz options (35.4%) were the next most useful options.
Responders’ perspectives on CPD for planetary health
The majority had no or limited familiarity with the topic of planetary health (n = 46, 58.2%) and had not been offered any such CPD in the last year (57.0%) as shown in Table 4. The majority had never attended a CPD event on planetary health (n = 48, 60.8%). The main barriers to CPD on planetary health were a lack of perceived relevance to clinical care, a lack of institutional or government support for these topics, and a lack of educational resources to support CPD.
Most responders (57.5–82.5%) recognised the relevance of planetary health topics to their patients (Table 5) and agreed with incorporating a brief planetary health perspective within CPD on clinical topics as well as including new CPD topics related to planetary health. The top five clinical topics combining all forms of agreement were: chronic respiratory problems, infectious diseases such as malaria, gastroenteritis, malnutrition, and cardiovascular disease together with diabetes. If only ‘strongly agree’ is considered, then mental health would also be included. The top five specific topics combining all forms of agreement were: how climate change impacts health, addressing environmental determinants through community-orientated primary care, how to make facilities and services more resilient and environmentally sustainable, and the health and social effects of heat. If only ‘strongly agree’ were considered then emergency and disaster preparedness for climate hazards, pollution, and mental health and psychosocial counselling during disasters would also be included.
Table 5 also presents agreement with potential strategies to integrate planetary health into clinical practice. The top five strategies were: evidence-based guidelines on climate-sensitive diseases; patient education material; clear plans for emergency preparedness and disaster management; incorporation of planetary health issues into policy; and tools to assess climate resilience of facilities and create action plans. Less than half agreed with the need for tools to measure the carbon footprint. In addition, only 27.5% (n=24) often or always include relevant counselling on health risks related to planetary health in their consultations.
Discussion
Summary
The majority of responders had little familiarity with the topic of planetary health and had never attended a CPD activity. They recognised its importance and agreed that it should be included in CPD. Specific clinical topics should include key information on planetary health issues and broader planetary health topics should be targeted in CPD programmes (for example, how climate change impacts health, how to improve the climate resilience of facilities and services). The alignment of suggested topics with the planetary health framework is shown in Supplementary Table 1. The neglect of planetary health topics in CPD was attributed to a perceived lack of clinical relevance, no institutional or government support and a lack of educational resources.
Strengths and limitations
Responders were members of the PRIMAFAMED network and were mostly family physicians attached to university departments. These family physicians were embedded in their primary care services and often trained nurse practitioners and clinical officers. However, the survey did not directly include the perspectives of nurses and clinical officers who make up the primary care workforce in many countries.
The survey included responders from 24 countries and 38 institutions in the network and included 95% of the intended institutions. The participants, however, were selected purposefully and not randomly to maximise response rate. These responders had engaged more actively with PRIMAFAMED and might be more positive about planetary health. The results may not be fully generalisable to the broader membership of these departments, including nurses and clinical officers, but are sufficient to guide the development of CPD within the network.
The field of planetary health is a broad ecosocial paradigm and the investigation of CPD did not cover the whole paradigm. Members of the PRIMAFAMED network focused on issues that related to clinical practice and were most familiar with climate change.
Comparison with existing literature
In terms of the overall perceived need for planetary health education, planetary health educators have identified the need to integrate planetary health into undergraduate curricula and several guidelines have been published.17–19 The findings of this study highlight the gap in CPD for primary care providers in sub-Saharan Africa. The responders were mostly family physicians connected to academic settings, and the exposure of other primary care providers is likely to be even less. In some countries such as Malawi the impact of climate change has enhanced the clinical relevance for clinicians,16 and in South Africa the need to build climate-resilient primary care services identified educational goals for the workforce.20 The Planetary Health Alliance underlines that there is a growing demand among educators for relevant educational resources to enrich their planetary health courses.21 The perceived need for CPD on planetary health may therefore be increasing.
Responders agreed that CPD on clinical topics should start to include information on relevant effects of climate change and planetary health. For example, CPD on chronic respiratory disease might discuss the effect of climate change on allergens,22 or the impact of metered dose inhalers on the environment.23 Likewise, CPD on malaria might discuss the effect of climate change on mosquitos as a vector,24 or the effect of extreme heat on kidney disease and diabetes.25 As the usual presenters might not be experts on planetary health, the provision of CPD resources such as short videos or PowerPoint slides might give them the confidence to include these topics.
Most responders had not discussed climate change or planetary health issues with patients, although did support having patient education materials. Globally, there is interest in developing planetary health counselling and education for patients.26–29 However, empirical evidence to support such consultation processes is weak and amplifies health professionals' discomfort for effective climate-sensitive health counselling.30
Responders also agreed that certain planetary health topics should be addressed. Although many health professionals are aware of climate change and health,31,32 they may still need to understand the linkages in more depth,33 and local application.34 Responders suggested that we identify experts in the region who could address these issues as well as publish articles that could support CPD on these topics. How a community-orientated approach can address climate hazards in specific communities also needs to be addressed,11 and participatory approaches to helping communities build climate resilience.35
In many high-income settings, there is an emphasis on mitigation, environmental sustainability and reducing the carbon footprint.36 This did not appear to be a priority amongst these responders from sub-Saharan Africa, which aligns with the small contribution of Africa to global greenhouse gas emissions.37 Nevertheless, there is some concern that the relative carbon intensity of health care per unit of expenditure may be higher in low- and middle-income countries and points to the need to find low-carbon pathways to development of health systems.38
Implications for practice
The findings will be used to develop resources for CPD within the PRIMAFAMED network and sub-Saharan Africa. We plan to develop a special collection of CPD articles within the African Journal of Primary Health Care & Family Medicine that address the recommended planetary health topics and are linked to eCPD.39 In addition, we plan to develop educational resources that can be integrated into other CPD activities, particularly on clinical topics. These may include short videos and PowerPoint slides with explanations and references in the notes. We also plan to develop a list of speakers who can present on planetary health topics from within the region or more globally via groups such as the WONCA Working Party on Planetary Health,40 SAAHE,41 or the Planetary Health Alliance.13 As we implement these educational initiatives and resources it will be necessary to evaluate implementation (for example, reach and adoption by CPD programmes, effects on participants, and feasibility of using the resources).
The lack of institutional and government support for CPD on planetary health should also be addressed. CPD providers such as professional bodies, higher education institutions, and health services should plan their programmes with planetary health as a priority topic for inclusion and encourage speakers on clinical topics to also address the relevant issues. CPD accreditors can encourage and even incentivise the inclusion of planetary health.
In conclusion, family physicians within the PRIMAFAMED network in sub-Saharan Africa have limited understanding of planetary health and have not been exposed to CPD on the topic. Despite this, the majority see the need for CPD that addresses relevant planetary health topics. There is a need to integrate an understanding of how planetary health is impacting common clinical conditions into CPD programmes, and to also address key planetary health topics. The findings point to a need to develop a toolbox of CPD resources, evaluate their implementation and enable more institutional and government support for CPD on planetary health.
Notes
Funding
The authors acknowledge the Flemish Interuniversity Council (VLIR) who provided a TEAM grant to support the research study (ZA2022TEA526A103) and our partners on the grant at the University of Ghent, Prof Ilse Ruyssen and Dr Charlotte Scheerens.
Ethical approval
Ethics approval was given by the Health Research Ethics Committee at Stellenbosch University (N24/01/003) and all responders gave electronic consent.
Provenance
Freely submitted; externally peer reviewed.
Data
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Acknowledgements
We acknowledge the members of the PRIMAFAMED network that helped to validate the questionnaire and identify responders.
Competing interests
The authors declare that no competing interests exist.
- Received August 14, 2025.
- Revision received October 21, 2025.
- Accepted November 12, 2025.
- Copyright © 2026, The Authors
This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)
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