Child mortality has significantly improved, yet in , 5. The Practical Approach to Care Kit PACK Child guide has the potential to expand on the gains of IMCI by blending preventive and curative care and providing algorithmic approaches to symptoms and long-term health conditions for the child from birth up to 13 years. PACK Child has the capacity to clarify clinician scope of practice and referral prompts to facilitate task sharing and expansion of the team of primary care clinicians delivering child care. Healthcare, and specifically universal access to care, is intrinsic to achieving these goals.
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Innovative approaches are required to improve the capacity of services and quality of care offered. The generic IMCI guideline requires adaptation for in-country needs, often with external technical assistance, and training involves an intensive, day, skills-based course. Implemented in over LMICs, 7 a foremost consideration in its development was the need to address the skills gap among frontline health workers in managing common childhood illnesses by providing a practical, easy-to-follow algorithmic approach to case management.
The results achieved with IMCI and lessons learnt are reported in several reviews, surveys and multicountry evaluations. In response, the programme incorporated a section on neonates, occasional updating, greater use of the syndromic approach, a focus on antibiotic stewardship, revised training and supervision methods, community health worker involvement and health system coordination.
Over the past 18 years, the Knowledge Translation Unit KTU of the University Cape Town Lung Institute South Africa , a health systems intervention unit, has investigated and developed evidence-informed methods to strengthen primary care service delivery in underserved communities. The Practical Approach to Care Kit PACK Adult programme was designed to support health workers to deliver policy-aligned, comprehensive and integrated primary care for adult patients. PACK and its predecessors have been implemented, scaled up and sustained across South Africa, with over 30 health workers trained since Four pragmatic randomised controlled trials evaluating these interventions showed modest but consistent improvements in quality of care, health outcomes and healthcare use, 22—25 with parallel qualitative evaluations reporting improved job satisfaction, work morale and a sense of empowerment.
The PACK training strategy, described in detail in another paper in this Collection, employs three key elements that allow for sustainable scale-up 21 : an educational outreach training, 28 a cascade model of implementation and support delivered by government-employed trainers, and a training methodology underpinned by adult education principles. Strong motivation for developing a version of PACK for children came from doctors and nurses who use PACK Adult daily in public sector primary care, and from paediatricians who recognised the need to improve primary care services both to ensure greater access to quality primary care for children and encourage more appropriate referral patterns to higher levels.
Both pointed to the need for an expanded scope of practice including children up to the age of 13 years. This paper describes the development of the first pillar, the PACK Child guide, its key features and lessons learnt during its development. Importantly, the PACK guide is not a text book but rather a clinical decision support tool designed for point-of-care use during clinical encounters. This may include several cadres of staff; doctors, nurses and, in some settings, physician assistants and community-extension health workers. We aimed to provide a guide with the following features: modelled on experience gained in the development of PACK Adult; suitable for use during primary care clinician consultations with children from birth up to 13 years; comprehensive in its coverage of reasons for attendance; fully integrated to enable cross-referencing for comorbidities; evidence-based, up to date, and in both book and electronic form.
The steps in the development of PACK Child were similar to those used for PACK Adult and drew on relevant elements from international norms and standards for trustworthy guideline development. This experience captured in the first version of PACK Child will be carried over into more generic versions of the guide. Development began January and the first version was completed in December Steps in development are presented in figure 1 and included the following:.
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The first step was to obtain high-level policy-maker endorsement and support for the project from the jurisdiction for which it was intended, the Western Cape government. This group comprised local child health clinicians primary care physicians, paediatricians, nurses and policy-makers who oversaw and guided the 2-year development process, assisted in defining the scope and content of the guide, and facilitated collaboration with potential peer reviewers. In , the Trust expanded its fundraising reach to other levels of health services. No funding from commercial enterprises, including pharmaceutical companies, was accepted.
Ethics approval was not required for the development process, as it was not conducted as part of a research study.
When deciding on the scope of PACK Child, the GDAG considered the opinions, knowledge and experience of local clinicians, available child morbidity statistics in the Western Cape, as well as findings from a cross-sectional survey of reasons for paediatric primary care encounters across four provinces in South Africa, performed in This content set is largely generalisable to most primary care settings although additional or adapted content is likely to be needed to address local disease profiles when localising for other settings.
A desk review was conducted of current local and international guidelines and online resources for the care of children at primary healthcare level relevant to LMICs. No single resource was found to address the objectives described above or to be suitable for adaptation. Based on the findings of the desk review, selected resources were consulted to develop each management algorithm. As most of the evidence-based clinical recommendations appearing in these resources were developed primarily for high-income country settings, each recommendation in PACK Child, though evidence-informed, had to pass the tests of availability of resources and feasibility within South Africa.
Further tailoring ensured alignment to latest Western Cape health policies and protocols and harmonisation between pages to avoid conflicting advice. Draft pages were subjected to stakeholder review by specialist clinicians, allied health professionals, doctors and nurses working in primary care and school health services, patient advocates and policy-makers during clinical working group sessions, and through individual peer review. Separate clinical working groups considered 10 topics: the well-child assessment, nutrition, respiratory, neurodevelopment, mental health, musculoskeletal conditions, parenting, tuberculosis, HIV and palliative care.
In addition, a group of eight primary care social workers reviewed criteria for referral to social services. Consultation with health officials developing clinic stationery for child care ensured alignment of the guide with proposed patient flow processes. Focus groups were held at the end of this period to obtain feedback.
A key consideration was whether clinical decision nodes in the algorithms were clear and easy to use. The response was positive and reassuring, prompting only minor adjustments and clarifications. An example of strongly positive feedback concerned the clarity of recommendations for prescribing an antibiotic.
Once complete, the full guide was sent for review to 69 clinical experts from various disciplines. They were requested to review particular sections within their field of expertise, with special attention to how this was embedded within the whole guide. None suggested removal of content but rather, refinements. The iterative correspondence with reviewers led to finalisation of the guide within 3 months.
This transparent methodology may have provided reassurance to key stakeholders and facilitated their endorsement of the guide. The final step involved obtaining comments and approval from local health authorities, governance structures and committees. In the Western Cape, approval had to be obtained from a Technical Working Group, which included operational, monitoring and evaluation expertise, the Regional Training Centre for nurses and the Nursing directorate. Furthermore, a comprehensive medicine list was prepared for the Provincial Pharmaceutical and Therapeutics Committee, whose authorisation was required for the use and confirmation of dose, duration and alignment with the South African Essential Medicines List.
Figure 2 showcases examples of the various formats of PACK Child pages: symptom-based approach figure 2A , standardised approach to routine care figure 2B and step-by-step illustrated guidance figure 2C. A Example of a symptom-based approach page.businesspodden.se/el-vizconde-demediado-biblioteca-calvino-n.php
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For the child not requiring urgent attention, an algorithm directs the health worker to a likely diagnosis and provides primary care management as well as appropriate referral prompts where a condition is complex, there has been poor response to initial treatment or there is any doubt about a diagnosis. B Example of a standardised approach to routine care page. C Routine care of the child is integrated into every visit. Growth is emphasised in the routine preventive care section with step-by-step, illustrated guidance on measuring, plotting, interpreting and reacting to growth parameters.
ART, antiretroviral therapy. Prompts for recognising children requiring urgent or elective referral are designed to encourage efficient use of services, and timeous access to higher levels of care. Indications, pathways and timeframes are clearly specified. Medications are colour-coded according to prescriber, which may differ by indication.
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Providing an extended scope of content table 1 including the needs of children over 5 years old. Actively guiding the clinician to integrate curative and preventive care at every visit. Facilitating task sharing by clarifying roles and responsibilities, referral criteria and prescribing levels. Table 2 uses clinical scenarios to practically demonstrate how the PACK features intend to reinforce the approach of IMCI and build on its limitations. The clinical working groups noted system issues relating to IMCI implementation: in many Western Cape facilities, one IMCI-trained nurse was responsible for managing almost all children attending that facility.
This sometimes limited the capacity of the clinic to offer care, further exacerbated by the uneven distribution of staff and curative and preventive care services across the region. This in turn was reported to influence referral patterns to doctors and hospitals.
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The hope was expressed that by training all categories of clinician in the care of children together, capacity might be increased and referral patterns improved. The inclusive PACK training may also ensure a pharmacist is kept up to date with approved treatments and doses and corresponding prescriber authorisation. The active involvement in the development of PACK Child of primary care doctors and nurses who often see around 60 children per day in stressful conditions served to sharpen recommendations on the basis of feasibility, in many instances tempering the advice and opinions of specialists.
This highlighted the practical challenge of successfully integrating preventive services into curative consultations and resulted in further refinement of the routine care pages and influenced the structure of the PACK Child training curriculum. The development process also highlighted the dearth of recommendations for the adolescent, especially for young girls seeking sexual and reproductive health services, which constitute many primary care attendances.
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