The findings are presented in three broad areas considering how delivery of PACK Child changed as the intervention evolved across the three phases of the pilot. First are findings from clinician interviews, triangulated with observations of PACK Child training sessions, of how different intervention components affected which change in clinical practice. Second, drawing on observations of consultations we present findings of intervention fidelity. Triangulated with clinicians’ reports of how they used PACK Child in everyday practice , we provide further insight into how different intervention components interacted with the existing healthcare context as well as barriers and facilitators to implementing PACK Child in routine practice.,. Finally, we report caregiver perspectives of their experience of PACK Child consultations and the extent to which the intervention met the carer’s and child’s needs.
The overall sample included four policymakers, 10 managers, 70 clinicians and 69 caregiver/child dyads, one KTU trainer and three trained clinicians delivering training within their facility. We conducted a total of: 10 non-clinical observations, 53 consultation observations, 31 observations of training sessions, 52 caregiver interviews (34 of whom also had their consultations observed), 10 clinicians’ focus groups and a stakeholder workshop with 23 participants. Sixty-four clinicians from all pilot clinics completed the clinician’s questionnaire six months after completing the PACK Child training sessions, a response rate of 65%. High staff turnover meant many staff who had been trained could not be contacted six months after completion of training (Table 2).
Table 2: Data collection across all phases of pilot
The influence of PACK Child on clinical practice
Overall, despite PACK Child lengthening consultations, the data collected suggested positive effects on clinical practice, improving clinical knowledge and practice, fostering teamwork, improving referral processes, and caregiver’s participation in the consultation process. This was in spite of several difficulties for clinicians in incorporating PACK Child within a practice usually focused on care of acute illness, time limitations and verticalized care with only designated nurses attending children.(16)
Length of consultations
Analysis of consultation observations suggested that where clinicians followed the PACK Child guide in detail, which included routine care for the well child, consultations were longer than where clinicians only partially used the guide. Other factors appearing to influence consultation length included the number of symptoms the child presented with, previously unidentified problems now identified through the clinician’s use of the guide, and staff using PACK Child who did not routinely attend children.
Table 3 shows the average consultation length in Phase Three was 7-8 minutes longer than the other two phases and included an average of 10-13 more questions per consultation. However, there were also a few extreme cases in Phase Three, with one consultation comprising 84 questions and lasting 52 minutes due to the child presenting with multiple problems that required assessment and which the nurse dealt with in turn.
Table 3. Length of consultations and average number of questions
Although use of PACK Child appeared to entail longer consultations, some staff reported that increased familiarity with the guide, through regular use over one or two months, would reduce the duration of consultations.
“Sometimes it takes too long, because I work alone in the room, and I have about 30 patients, sometimes more than 30 that I see in a day, then it takes a while, but the more you familiarize yourself with the guideline it will go quicker, because you'll know the questions to ask, but for now it's taking a little bit of time.” (Professional Nurse, Focus group, Phase 3)
Improving clinical knowledge and practice
Eighty-seven per cent of surveyed clinicians reported that the PACK Child guide and training programme improved their ability to both diagnose and treat children even though 85% of them were already trained in IMCI.
One area where this was especially pronounced was on growth monitoring. One of the training sessions is dedicated to embedding correct monitoring and interpreting growth in children. Using case scenarios, clinicians are asked to plot children’s growth measurements on a chart and interpret their growth using the PACK Child guide. Many nurses initially struggled to determine where to plot measurements on growth monitoring charts. After this session, staff reported growing confidence in their ability to plot and interpret the growth of children.
“And the assessing and interpreting the growth let alone the minor things, plotting the growth chart which we were doing, but now we know how to do it in the right way. But now that we have done PACK Child, we know the way to do and assess whether they are implementing it right. It starts with weigh, measuring and plotting. If you plot wrongly, it will be interpreted wrongly...” (Clinical Nurse Practitioner, Focus group, Phase 2)
PACK Child’s expanded scope of content to include long-term health conditions like HIV, tuberculosis, eczema and asthma appeared to influence clinicians’ management and diagnosis of long-term health conditions and conditions not covered extensively by IMCI, such as skin conditions.
“For example, I can say PACK guideline is very helpful, because I'm going to mention like skin symptoms. I used to see a child with a rash, but I couldn't differentiate what is it really, but when I go to the PACK Child, I know I can name it. It has got its specific diagnosis. I know what it is. But when I look at the PACK Child and I look at the child, then I see exactly what is in the PACK Child, and also what kind of treatment. It's very helpful.” (Clinical Nurse Practitioner, Focus group, Phase 3)
“According the PACK guideline it shows you exactly on the X-ray what type of TB it is on those pictures. So you can start(TB treatment) already. Doctor cannot say you were not supposed to start, because you have other things also to back you such as the Mantoux or the weight loss and all those things. So then you can just continue and confirm with the doctor.” (Professional Nurse, Focus group, Phase 2)
Several nurses appreciated guidance in PACK Child for children over five years, guidance that was previously limited.
“So, with PACK Child it's much better, you feel more secure that now you can treat the child until 12/13 years old.” (Clinical Nurse Practitioner, Focus group, Phase 2)
Many clinicians also reported that the algorithms were clearer in PACK Child than in IMCI despite having the same or similar information.
“What we have noticed is that the algorithm we have got from PACK Child is more clearer than IMCI, although the information is the same or similar, but it is more clearer.” (Clinical Nurse Practitioner, Phase 2)
However, clinicians experienced some difficulty in shifting the focus of care from an acute episodic paradigm to one of long-term health conditions, especially in the management of recurrent respiratory conditions. Several doctors reported being hesitant in supporting nurses to prescribe inhaled medication, potentially discouraging nurses’ from taking advantage of the expanded content of PACK Child.
“In the asthma case presented in the session, the child presented with a recurrent wheeze for five days. The child was given a trial of an inhaler, but the clinicians omitted checking the bronchodilator response before prescribing. The doctor in the training felt that nurses would be prone to abuse inhalers if they were not assessing how previous episodes were managed and the correct diagnostic process followed including checking bronchodilator response.” (Field notes, Observations of Session 7: Long Term Health Conditions, Phase 3)
A key function of the PACK Child training approach, through the inclusion of all cadres of clinicians, was to encourage collaborative working in order to reduce verticalized delivery of paediatric primary care. Although enrolled nurses and pharmacists reported that much of the training was not directly relevant to their current role, they expressed the value of the training for orientating them to a broader scope of paediatric primary care and the benefits of collaborative working for sharing knowledge. Enrolled nurses also noted that the training helped to delineate the roles and responsibilities of different cadres so that tasks were shared and enabled greater collaboration across clinical staff.
“For me, as a junior nurse, I thought perhaps why am I involved in this, because now I see this book that is being used by the CNPs and the doctors but now as I’ve gone along, and ((trainer)) brought a triage page which specifies what is it that us junior nurses we need to do, before the child could go to a CNP. I saw it very much helpful. So that the CNP or the clinician doesn't take much time in doing the little things that was supposed to be done by us.” (Enrolled Nurse, Focus group, Phase 3)
The “health system strengthening session”, which primarily focused on the flow of children through the clinic, facilitated changes in some facilities. Where verticalization of care was predominant such as one nurse weighing all the children, nurses in consultation rooms began to alleviate the burden of tasks traditionally limited to certain cadres, which promoted task-sharing amongst clinicians.
“We don't need to move the child from your room. You can weigh the child there.” (Professional Nurse, Focus Group, Phase 2)
Facilities reported that triaging of children was streamlined, and nurses felt equipped to identify children needing referral within the clinic, which fostered team work and shorter waiting times.
“The other thing for triaging of the patients, the babies they really get emergency care much quicker, also their routine screening is so much easier with the length mat is there, everything is there. So, the staff have really benefitted from the training.”(Manager, Phase 2)
“What I have noticed is that she is always consulting, she is knowledgeable, almost to her utmost best of what is in PACK. But I have not seen her coming to me with a challenge she cannot go beyond. Even those kids that are referred to the emergency section. Sometimes, she doesn’t even come to me. She picks up the problem for the emergency and she send them without my intervention.” (Clinical Nurse Practitioner, Focus group, Phase 2)
“I can say I have a lot of children coming with a lot of skin conditions and now I can treat them. Because they come in and say I want to be referred to ((name of hospital)). And I didn’t need to refer them, I say let us just try our treatment here, that is why I say unnecessary referrals to tertiary level. So now I am treating them here and they are coming back in a months’ time to review the skin.” (Clinical Nurse Practitioner, Stakeholders workshop, Phase 3)
During qualitative interviews, nurses reported that use of the screening tools within PACK Child led to them identifying more children with problems that required referral. For this nurse, this was specifically in relation to identifying overweight children requiring referral, utilising PACK Child’s guidelines and parameters for children’s growth and development.
“We picked up lots of obese babies, of which now we are referring to the dietician and the dietician now has something to do. Before we were only picking up children with malnutrition. We didn't consider the obese, now we know when to refer, we know which weight is expected of each child, so we know when to refer. So now really it is of help.” (Clinical Nurse Practitioner, Focus group, Phase 2)
In Phase One, despite improved identification of children requiring referral, nurses reported frustration with the lack of feedback from hospitals. To address this, the PACK Child intervention team set up a meeting with the local hospital to orientate the staff there to PACK Child and discuss existing referral challenges. Despite this, poor communication of the outcome of referrals to hospital care persisted. However, in Phase Two PACK Child’s standardised approach for referral of children influenced how some clinician’s felt about referring to secondary care, describing that they felt more able to communicate effectively with secondary care clinicians.
“Even if we phone a doctor to refer a child at the hospital, you know exactly what you're talking about. It's not like you question yourself, as it is in the guide.” (Professional Nurse, Focus group 3, Phase 2)
Improvements in psychosocial risk screening
According to clinicians, use of PACK Child in consultations led to more psychosocial risk issues being identified in consultations, resulting in some referral and resolution of these disclosures.
“It prompted you now with that section to ask for social problems. I also had one child: she didn't have an ID. Mum didn't have an ID that’s why she didn't register the child, and she can't apply for a grant, and I helped her. So that section is really good. It prompts you to ask those questions. In the past we overlooked it.” (Clinical Nurse Practitioner, Focus Group, Phase 2)
However, introduction of routine psychosocial risk questions, in an embedded checklist approach to consultations, appears to result in nurses asking the questions in such a way that limit disclosure of psychosocial problems. Due to the volume of questions to be covered in a consultation, questions are framed in a way to rule out problems instead of encouraging disclosure.(16) Furthermore, in some cases, where disclosures were made, the clinician could be seen to minimise its importance or not address the disclosures made by caregivers. This excerpt describes the lack of human resources and one of the reasons why issues that were disclosed may have been minimised.
“We have a problem with psychiatrist. If you get the problem of abuse, then you must send the child to the hospital, because we don't have a person here every day, that's also a problem. Sometimes when you book the people, for that then the guy cancels his visit.” (Professional Nurse, Focus Group, Phase 3)
Implementation fidelity of PACK Child
The PACK Child training encouraged clinicians to approach a consultation in a standard way using the PACK Child guide, starting with an assessment for urgent symptoms and in their absence proceeding to provide well child routine care. Clinicians were trained to navigate the guide for the relevant symptom/s, or long-term health conditions (LTHC) only once they had completed routine care activities.
Our findings revealed several contextual issues which interacted with clinicians’ use of the PACK Child guide, affecting fidelity to the training programme’s instructions around guide use within consultations. These included how clinicians articulated their use of the PACK Child guide alongside existing documentation and reporting requirements, the approach to guide use (particularly around well child routine care) and the aspirational expectations of what care could be delivered during a consultation.
Navigating PACK Child within current routine practice
Implementation of the PACK Child approach during consultations was variable and each facility’s requirement to use multiple documents resulted in clinicians alternating between different documents and consultation activities. Table 4 illustrates how the PACK Child approach to consultations was interrupted as clinicians switched between different routine care and symptom-based activities and various sections of the guide, whilst also completing necessary documentation. In particular, clinicians typically struggled to follow the consultation sequence recommended by PACK Child guide and training.
Table 4. Activity coding across phases of consultation structure
Clinicians were able to reflect on the complexity of following different documentation and reported feeling torn.
“Because our mind is now still divided. I’ve the PACK, I’ve got the IMCI, you understand? Sometimes if you go now to say, ok, I think I'm more comfortable with the PACK style. Now you more comfortable rather on this, then you mind goes that way.” (Professional Nurse Interview, Phase 1)
A key finding from this work was that the consultation sequence (assess symptom urgency-well child routine care-symptom management) proposed by PACK Child differs from that of the IMCI checklist, requiring clinicians to embrace a new consultation flow. This was especially apparent in Phase One, when the IMCI checklist stationery was used consistently within consultations. Clinicians frequently switched between PACK Child, the IMCI checklist and Road to Health Booklet, often repeating questions that appeared in these documents. This switching between documents, and between routine care and symptom-based activities indicated that staff struggled to navigate between documents and manage the volume and range of tasks required to use PACK Child to attend to both the children’s symptoms and their need for well child routine care. In response to these findings, the PACK Child training included two additional components in Phases Two and Three. Firstly, a “health system strengthening session” was included which asked clinicians to map the flow of patients within their facility. This enabled clinicians to consider how to reorganise and reallocate tasks in order to relieve the burden on clinicians in the consultation rooms. Secondly, additional elements were added to an existing session which focused on how best to integrate PACK Child alongside documentation.
Despite introducing the health systems strengthening training session, Phases Two and Three facilities did not make any significant changes to how they organised patient flow and allocation of tasks across clinicians. However, in Phase Two, two of three facilities used blank clinical continuation notes to document findings instead of the IMCI checklist. In Phase Three, whilst there was a mixture of documentation in use, (PACK Child guide, IMCI checklist, Integrated Clinical Stationery) a larger proportion of children above six years (for whom no formal documentation exists) meant that no specific stationery was used within these consultations. Within these consultations, we unsurprisingly identified less switching between documents. However, in both Phases Two and Three we still observed clinicians frequently switching between activities within the PACK Child guide (e.g. assessment of urgency, symptom management, routine care), sometimes doing so before completing an activity, necessitating returning later to complete it.
Following the PACK Child guide as a script
The distribution of question types shown in Table 4 provides insight into how elements of PACK Child were incorporated into consultations across the three phases, within the embedded IMCI checklist approach. Whilst in Phase Three we still observed switching across activities within the PACK Child guide, analysis of clinician’s questioning within consultations suggested that clinicians in Phase Three more closely followed and completed each activity of the guide as proposed within the training sessions.
In all phases the top four question types were oriented to acute symptom management [see Additional file 5], growth monitoring, immunisations, and TB and HIV characteristic of IMCI despite the expanded scope of PACK Child. In Phase Three there were an average of 7.6 questions focused on wider information gathering compared with 2.1 questions in Phase One and 2.9 in Phase Two. These differences may indicate closer fidelity to PACK Child symptom algorithms in Phase Three, but might also reflect the nature of children’s individual problems within each phase. However, an average of 4.4 psychosocial questions per consultation were also asked in Phase Three compared with 1.4 and 3.6 questions for Phases One and Two respectively indicating closer fidelity to routine care questions.
From our direct observations within consultations, we also identified instances of nurses meticulously following every element of the guide in Phase Three, which closely reflected how facility trainers were trained in Phase Three, with emphasis to follow every relevant line of the PACK Child guide within a consultation.
"The training it teaches us that you actually should read to the end, but here now you just grab important things that you catch, but by right we actually supposed to read the whole thing in order to go to the next step.” (Clinical Nurse Practitioner, Focus group, Phase 3)
Integrating well child routine care into the consultation
The identification of clinician difficulty in following the routine care-symptom consultation sequence prompted an important analytical issue: How does asking routine care questions affect the management of a child’s symptoms? We identified that, on average, more symptom questions (reported complaint and wider information gathering combined) were asked when the Routine Care page was not used compared with when it was [see Additional file 6]. It is important to note that this is any use of the Routine Care page, not necessarily complete coverage of all items listed on the page. In many instances nurses only partially used the Routine Care page, missing out several questions, typically around sensitive psychosocial issues.
“I think it is a time thing, the Routine Care goes through quite a lot of psychosocial questions and I suppose those are the ones that I probably leave out.” (Clinical Nurse Practitioner, Focus group, Phase 3)
When the Routine Care page was used, nurses were sometimes not returning to the child’s reported complaint following routine care, leaving the complaint unaddressed, or not resolved according to PACK Child recommendations. This demonstrates the difficulty clinicians had in attending to both routine care and the presenting symptoms, with some clinicians reporting a tendency to forget the presenting symptoms.
“You ask symptoms, it may be related to the skin and no urgent signs whatever the case may be and then we have to go routine care, and then we need to note we have to go back and then continue from there, which is where Sister picked up the weight and things which was more alarming because her initial thing that was noted. So that is where Sister also forgot about the symptoms, which was the skin. So, the Routine Care page is a big help, it is a big help, but it is just the back and forth as Sister say.” (Professional Nurse, Focus group, Phase 3)
Caregiver/child perspectives on the impact of PACK Child on their care
Caregivers frequently shared past experiences of bringing their children to the clinic for consultations where the primary focus of care was restricted to the acute presentation.
“But with them if I say his ears are sore, they won't check anything else.” (Caregiver Interview, Phase 1)
“Normally the doctors just look. They don't ask a lot of questions. They just look and then they tell you, no it's not like that and it's not like that. The child's fine, you can go.” (Caregiver Interview, Phase 3)
The focus on acute symptoms was identified by caregivers as the core element of most paediatric primary care consultations. Although sometimes attending with recurrent symptoms, caregivers reported that clinicians rarely asked about the child’s previous history or referred to documentation, instead treating each episode separately.
“Interviewer: And when you come for the same problem, do they check that she had it before, or do they just treat it like it's new?
Caregiver: They never do, they never like look on her records before, normally she does have tonsils, then they give tablets or something.”(Caregiver Interview, Phase 3)
The caregiver view that nurses do not investigate the child’s medical history, lack the knowledge to diagnose and adequately treat their child, and that the caregiver feels uninformed.
“Interviewer: Have you brought him to the clinic for the tight chest.
Caregiver: I have come many times
Interviewer: Have they given him anything?
Caregiver: They give an inhaler. The chest is too tight.
Interviewer: Have they said what it is?
Caregiver: They don’t know, it’s like they don’t know, and I don’t know.
Interviewer: Did they refer you to anybody.
Caregiver: No, they don’t. They don’t want to check what is wrong, he is still using the inhaler.” (Caregiver Interview, Phase 1)
However, interviews with caregivers emphasised the influence of PACK Child’s broadened scope of content on the clinical assessment process. They, frequently reported a marked shift in the questions they were asked in PACK Child consultations compared with that prior to the pilot, which they linked to the clinician’s use of the PACK Child guide.
“It has changed because there was not that book, like there were not those kinds of questions because the last time I was here, I also came for the same problem, but it was not the same he has sore wounds, like there was a wound here, that I came for, but there was not this book asking such questions, they didn’t ask so many questions, like they just gave me medication.” (Caregiver Interview, Phase 3)
Caregivers also reported that they were not routinely given scheduled visits for their children’s long term health conditions, but with PACK Child an appointment was given.
“I just bring (her) in when I see that the nebulizer at home isn't helping, but now the sister gave me three-month supply with the medication, and she gave me an appointment for after the 3 months; to see us which didn't happen previously.” (Caregiver, Phase 3)
Caregivers often conceptualised quality of care in terms of their level of participation in the consultation. Many caregivers reported that when the PACK Child guide was used there was opportunity for them to explain their story, clinicians explained what was happening and that they felt central to the decision-making process. This excerpt illustrates the contrast with caregivers’ experience of previous visits to the clinic:
“Because it’s the third time. Sometimes you go to the doctor then the doctor says, just that one thing. Like this was now nice. Everything was asked, and they have the patience to explain everything. And feel free to explain everything. Sometimes you go to the doctor, you just get cut you off because they rush you to get to another patient. Then that happens all the time.” (Caregiver Interview, Phase 3)
Caregivers valued being given the space and time to talk and ask things that were important to them, a sentiment frequently expressed following PACK Child consultations.
“And it was something good that I’ve learnt today, and I hope they keep it this way; to ask all those questions, and they took their time with us. It was not like before, where the time was really short.” (Caregiver Interview, Phase 3)
“Yeah, the way the doctor handled it. It was nice for me, because just for the fact that I can talk a lot of things ask lot of things. He come for his nose, but I could ask for this… she saw the marks of the eczema, almost like eczema.” (Caregiver Interview, Phase 3)
Explanation was defined as key to participatory care by caregivers, without the caregiver needing to ask for information. Caregivers described being unable to question nurses when they did not understand the jargon they used. In order to foster participation of caregivers in consultations, using language which caregivers understand is essential, and caregivers stated this occurred when PACK Child was used.
“The only difference is, like now with this consultation. She explained to me properly. A lot of the time the sisters were doing stuff, or give you something, but they don’t explain to you what is going on. You must always ask, and you feel so stupid sometimes. You must always ask to explain something to me properly, because you don’t know the jargon. So now you have to ask every detail and stuff like that. And sometimes they will look at you like you silly, and so that’s the only difference, that they explain to you stuff.” (Caregiver Interview, Phase 3)
Although many caregivers reported improvements in their level of participation in consultations, this was not reflected in how several clinicians viewed the effect of PACK Child on the clinician-caregiver interaction. They perceived the demands of completing documentation as a barrier that limited their ability to focus their attention on the caregiver and child.
“If you look at the paperwork, you write down on your IMCI form, you have to write down on your clinical as well, you have to write your script. We supposed to write in the child’s book, that we must be honest that is not done. You see how many different documents we need to write on. On top that, you starting to mix your medication, you are starting do all this. If you look at it, you more busy writing. You more focusing on writing instead of focusing on the child.” (Professional Nurse Interview, Phase 1)