Empowering frontline providers to deliver universal primary healthcare using the Practical Approach to Care Kit

Fairall, Lara; Cornick, Ruth; Bateman, Eric D.

doi:10.1136/bmj.k4451

Cited by 24 publications

(32 citation statements)

References 29 publications

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“…IMCI was introduced in South Africa in 1996 with a primary implementation focus capacity building of clinicians [17]. In the Western Cape, the main manifestations chart booklet, last updated in 2014, a training programme that targets professi the intention that they then see children, and the IMCI checklist (Additional file 2).…”

Section: Resultsmentioning

confidence: 99%

“…To help address these gaps, the Knowledge Translation Unit (KTU) in Cape Town, South Africa developed a paediatric version of its Practical Approach to Care Kit, (PACK) [16], intervention, comprising of a clinical decision support tool, training programme, and health system strengthening including enhanced supervision with regular updates as guidance and policies change [17][18][19][20]. PACK Child incorporates IMCI content but provides extended clinical guidance for the child older than 5 years (up to age 13), 16 long-term health conditions, an approach to the well child and additional nonlife-threatening, yet common conditions.…”

Section: The World Health Organizations' (Who) Integrated Management mentioning

confidence: 99%

“…The implementation and training elements of PACK Child are modelled on and complement PACK Adult [18], which was trialled and scaled up in South Africa to over 30 000 clinicians in more than 3500 clinics [21][22][23], using a systematic, educational outreach training strategy and cascade model of implementation [19]. PACK is also being implemented in Botswana [24], Brazil [25], Nigeria [26] and Ethiopia [27], is available globally through a partnership with BMJ (pack.bmj.com) and is being localised for piloting in China [17].…”

Section: The World Health Organizations' (Who) Integrated Management mentioning

confidence: 99%

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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)

Murdoch

Curran

Cornick

et al. 2020

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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.

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Section: Resultsmentioning

confidence: 99%

Section: The World Health Organizations' (Who) Integrated Management mentioning

confidence: 99%

Section: The World Health Organizations' (Who) Integrated Management mentioning

confidence: 99%

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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)

Murdoch

Curran

Cornick

et al. 2020

Preprint

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“…Led by the University of Cape Town's Knowledge Translation Unit (KTU), the PACK Child intervention was developed, comprising a clinical decision support tool (the PACK Child guide), a cascade training and implementation programme, and health system strengthening components. This was based on the Practical Approach to Care Kit (PACK) Adult programme that has supported the delivery of comprehensive, integrated adult primary care in the province for the past 14 years (8,9). Implementation of a health system strengthening intervention like PACK in a health system is a complex activity, requiring an understanding of how it will interact with the varying contexts of delivery.…”

Section: Introductionmentioning

confidence: 99%

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

Curran

Murdoch

Bachmann

et al. 2020

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Background: The WHO’s Integrated Management of Childhood Illness (IMCI) has resulted in progress in addressing infant and child mortality. However, unmet needs of children continue to present a burden upon primary healthcare services. The capacity of services and quality of care offered require greater support to address these needs by extending and integrating curative and preventive care for the child with a long-term health condition and the child older than 5, not prioritised in IMCI. In response to these needs, the PACK Child intervention was developed, to expand the scope of integrated management and training programmes for paediatric primary care. We report health worker and caregiver perspectives of the existing paediatric primary care context as well as the extent to which PACK Child functions to address perceived problems within the current local healthcare system. Methods: This process evaluation involved 52 individual interviews with caregivers, 10 focus group discussions with health workers, 3 individual interviews with trainers, and 31 training observations. Interviews and focus groups explored participants’ experiences of paediatric primary care, perspectives of the PACK Child intervention, and tensions with implementation in each context. Inductive thematic analysis was used to analyse verbatim interview and discussion transcripts.Results: Perspectives of caregivers and health workers suggest an institutionalised focus of paediatric primary care to treating children’s symptoms as acute episodic conditions. Health workers’ reports imply that this focus is perpetuated by interactions between contextual features such as, IMCI policy, documentation-driven consultations, overcrowded clinics and verticalised care. Whilst these contextual conditions constrained health workers’ ability to translate skills developed within PACK Child training into practice, the intervention initiated expanded care of children 0-13 years and those with long-term health conditions, enhanced professional competence, improved teamwork and referrals, streamlined triaging, and facilitated probing for psychosocial risk.ConclusionPACK Child appears to be catalysing paediatric primary care to address the broader needs of children, including long-term health conditions and the identification of psychosocial problems. However, to maximise this requires primary care to re-orientate from risk minimisation on the day of attendance towards a view of the child beyond the day of presentation at clinics.

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“…Led by the University of Cape Town's Knowledge Translation Unit (KTU), the PACK Child intervention was based on the Practical Approach to Care Kit (PACK) Adult programme that has supported the delivery of comprehensive, integrated adult primary care in the province for the past 13 years. (8,9) Implementation of a health system strengthening intervention like PACK in a health system is a complex activity, requiring an understanding of how it will interact with varying contexts of delivery.…”

Section: Introductionmentioning

confidence: 99%

Strengthening the quality of paediatric primary care: A process evaluation of a complex health systems intervention in South Africa

Curran¹,

Murdoch²,

Cornick³

et al. 2019

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BACKGROUND: Innovative strategies like WHO's Integrated Management of Childhood Illness (IMCI) have resulted in progress in addressing infant and child mortality. However, the needs of children continue to present a burden upon primary healthcare services. The capacity of services and quality of care offered require greater support to address these needs and extend integrated curative and preventive care, specifically, for the well child, the child with a long-term health condition and the child older than 5 years, not included in IMCI. In response to these needs, the PACK Child intervention was developed, based on a similar successful approach in adults, that expands the scope and reach of integrated management and training programmes for paediatric primary care. We report findings from the process evaluation of the integration of PACK Child intervention within the existing primary health care system. METHODS: A mixed methods process evaluation was completed in ten primary health care facilities in the Western Cape province in South Africa, where clinicians were trained to integrate PACK Child into routine practice. Qualitative data included transcribed interviews with managers, clinicians, caregivers and policymakers; audio-recordings and observational fieldnotes of training, consultations and clinic flow. Quantitative data were collected from training logs, questionnaires, and consultations. Qualitative data were analysed using linguistic ethnographic techniques, including conversation and thematic analysis. Quantitative data were analysed descriptively. RESULTS: Influence of PACK Child on clinical practice: Longer consultations, improved clinical knowledge and practice, better teamwork, strengthening of appropriate referrals and inclusion of psychosocial risk screening. Implementation fidelity of PACK Child was hindered by over-reliance on documentation and embedded checklist approach to consultations limited to acute episodic illnesses. PACK Child increased caregiver participation during consultations. CONCLUSIONS: The PACK Child intervention has strengthened primary care for children despite institutionalised care provided by a limited number of clinicians focusing on acute illness with little participation of the caregiver. With refinement of the programme, there is potential for PACK Child to strengthen paediatric care in low-resource settings. 3

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Empowering frontline providers to deliver universal primary healthcare using the Practical Approach to Care Kit

Abstract: Lara Fairall and colleagues reflect on the successes and challenges of a programme to strengthen primary healthcare in low and middle income countries

Cited by 24 publications

References 29 publications

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)

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)

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

Strengthening the quality of paediatric primary care: A process evaluation of a complex health systems intervention in South Africa

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