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Research article
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)
Jamie Murdoch
University of East Anglia
Corresponding Author
ORCiD: https://orcid.org/0000-0002-9021-3629
License:
This work is licensed under a CC BY 4.0 License. Read Full License
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.
Keywords
Child health; Health systems evaluation; Paediatrics; Prevention strategies; Other study design
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On 07 Apr, 2020
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Editorial decision: Minor revision
On 05 Apr, 2020
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Received 01 Apr, 2020
Review #1 received
Received 23 Mar, 2020
Reviewer #2 agreed
On 20 Mar, 2020
Reviewers invited
Invitations sent on 13 Mar, 2020
Reviewer #1 agreed
On 13 Mar, 2020
Editor assigned
On 27 Feb, 2020
Submission checks complete
On 26 Feb, 2020
Editor invited
On 26 Feb, 2020
No comments provided
Editorial decision: Minor revision
On 14 Feb, 2020
Review #3 received
Received 24 Jan, 2020
Review #2 received
Received 24 Jan, 2020
Review #1 received
Received 24 Jan, 2020
Reviewer #4 agreed
On 15 Jan, 2020
Reviewer #3 agreed
On 14 Jan, 2020
Reviewer #2 agreed
On 10 Jan, 2020
Reviewer #1 agreed
On 03 Jan, 2020
Reviewers invited
Invitations sent on 20 Dec, 2019
Editor assigned
On 16 Dec, 2019
Submission checks complete
On 12 Dec, 2019
Editor invited
On 12 Dec, 2019
First submitted
On 03 Dec, 2019
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This preprint is under consideration at BMC Health Services Research. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
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)
Jamie Murdoch
University of East Anglia
Corresponding Author
ORCiD: https://orcid.org/0000-0002-9021-3629
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Under Review
Version 3
Posted 13 Apr, 2020
No community comments so far
Submission checks complete
On 07 Apr, 2020
No comments provided
Editorial decision: Minor revision
On 05 Apr, 2020
Review #2 received
Received 01 Apr, 2020
Review #1 received
Received 23 Mar, 2020
Reviewer #2 agreed
On 20 Mar, 2020
Reviewers invited
Invitations sent on 13 Mar, 2020
Reviewer #1 agreed
On 13 Mar, 2020
Editor assigned
On 27 Feb, 2020
Submission checks complete
On 26 Feb, 2020
Editor invited
On 26 Feb, 2020
No comments provided
Editorial decision: Minor revision
On 14 Feb, 2020
Review #3 received
Received 24 Jan, 2020
Review #2 received
Received 24 Jan, 2020
Review #1 received
Received 24 Jan, 2020
Reviewer #4 agreed
On 15 Jan, 2020
Reviewer #3 agreed
On 14 Jan, 2020
Reviewer #2 agreed
On 10 Jan, 2020
Reviewer #1 agreed
On 03 Jan, 2020
Reviewers invited
Invitations sent on 20 Dec, 2019
Editor assigned
On 16 Dec, 2019
Submission checks complete
On 12 Dec, 2019
Editor invited
On 12 Dec, 2019
First submitted
On 03 Dec, 2019
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
License:
This work is licensed under a CC BY 4.0 License. Read Full License
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.
Figure 1