Addressing the quality and scope of paediatric primary care in South Africa: Evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child)

Abstract

Background: Despite significant reductions in mortality, preventable and treatable conditions remain leading causes of death and illness in children in South Africa. The PACK Child intervention, comprising clinical decision support tool (guide), training strategy and health systems strengthening components, was developed to expand on WHO’s Integrated Management of Childhood Illness programme, extending care of children under 5 years to those aged 0-13 years, those with chronic conditions needing regular follow-up, integration of curative and preventive measures and routine care of the well child. In 2017-2018, PACK Child was piloted in 10 primary healthcare facilities in the Western Cape Province. Here we report findings from an investigation into the contextual features of South African primary care that shaped how clinicians delivered the PACK Child intervention within clinical consultations.Methods: Process evaluation using linguistic ethnographic methodology which provides analytical tools for investigating human behaviour, and the shifting meaning of talk and text within context. Methods included semi-structured interviews, focus groups, ethnographic observation, audio-recorded consultations and documentary analysis. Analysis focused on how mapped contextual features structured clinician-caregiver interactions. Results: Primary healthcare facilities demonstrated an institutionalised orientation to minimising risk upheld by provincial documentation, providing curative episodic care to children presenting with acute symptoms, and preventive care including immunisations, feeding and growth monitoring, all in children 5 years or younger. Children with chronic illnesses such as asthma rarely receive routine care. These contextual features constrained the ability of clinicians to use the PACK Child guide to facilitate diagnosis of long-term conditions, elicit and manage psychosocial issues, and navigate use of the guide alongside provincial documentation. Conclusion: Our findings provide evidence that PACK Child is catalysing a transition to an approach that strikes a balance between assessing and minimising risk on the day of acute presentation and a larger remit of care for children over time. However, optimising success of the intervention requires reviewing priorities for paediatric care which will facilitate enhanced skills, knowledge and deployment of clinical staff to better address acute illnesses and long-term health conditions of children of all ages, as well as complex psychosocial issues surrounding the child.

Addressing the quality of paediatric primary care: Health worker and caregiver perspectives from a process evaluation of PACK Child, a health systems intervention in South Africa

“…First, we report four themes from our analysis which provide insight into the paediatric primary care context prior to PACK Child implementation. These ndings expand on our previous ndings from consultation observations [12], that identi ed an institutionalised orientation to treat children's symptoms as acute conditions, rather than as potential markers of underlying long-term health conditions. They provide insight into the wider context into which implementation of the PACK Child intervention was introduced.…”

“…The use of standardised prompting limited the potential for caregivers to interject in the usual checklist process. This re ected our observations of consultations which displayed a predominance of questions designed to e ciently progress through a series of IMCI questions with limited caregiver involvement [12].…”

“…However, the capacity for health workers to routinely provide this level of questioning was viewed as problematic by several health workers, despite caregivers noticing an increase in the depth of questioning and more opportunities for them to express themselves. Our observations of the PACK Child guide being used in consultations were that the perspectives of caregivers were rarely elicited [12]. Health workers explained that, because of the need to enquire more broadly in following PACK Child algorithms, as well as those of IMCI if the child was under 5 years, some questions and elements of algorithms were often bypassed.…”

“…We have previously reported ndings from observed consultations of how the implementation of PACK Child interacted with the wider context of paediatric care [12]. This paper complements those ndings by reporting the perspectives of caregivers of children attending the facilities, and of health workers responsible for delivering the PACK Child intervention.…”

“…However, health workers expressed concerns about translating the skills developed within training sessions into their practice setting [12]. As the following extract from observational eldnotes indicates, this di culty led to a doctor reporting that she was hesitant about supporting nurses to prescribe inhaled asthma medication.…”