Background: Despite significant reductions in mortality, preventable and treatable conditions remain leading causes of death and illness in children aged under five in South Africa. The PACK Child intervention, comprising a 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, and in 2017-2018 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 semi-structured interviews, focus groups, observation, audio-recorded consultations and documentary analysis. Linguistic ethnographic analysis of relationship between primary care contextual features and clinician-caregiver interactions.
Results: Primary healthcare facilities demonstrated dominance of a risk minimisation approach 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 received routine care. These contextual features constrained the ability of clinicians to use the PACK Child intervention 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 risk minimisation on the day of an acute presentation and a larger remit of care for the child over time. However, to optimise 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.