BMC Health Services Research

Strengthening 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)
--Manuscript Draft--

Manuscript Number: BHSR-D-19-02750

Full Title: Strengthening 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)

Article Type: Research article

Abstract: 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.

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Strengthening 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
1 Child)
2
3
4
5 Jamie Murdoch, Robyn Curran, Ruth Cornick, Sandy Picken, Max Bachmann, Eric Bateman,
6 Makhosazana Lungile Simelane, Lara Fairall
7
8
9 School of Health Sciences, University of East Anglia, Norwich, UK, NR4 7TJ
10 Jamie Murdoch
11
12 Senior Research Fellow in Process Evaluation
13
14 Norwich Medical School, University of East Anglia, Norwich, UK, NR4 7TJ
15
16
Max Bachmann
17 Professor of Health Services Research
18
19 University of Cape Town Lung Institute, Knowledge Translation Unit, University of Cape Town,
20
21 South Africa, Mowbray 7700
22 Robyn Curran
23 Process Evaluation Researcher
24
25
26 University of Cape Town Lung Institute, Knowledge Translation Unit, University of Cape Town,
27 South Africa, Mowbray 7700
28 Eric D Bateman
29
30 Emeritus Professor
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32 University of Cape Town Lung Institute, Knowledge Translation Unit, University of Cape Town,
33
34 South Africa, Mowbray 7700
35 Ruth Cornick
36 Senior Lecturer, Department of Medicine, University of Cape Town
37
38
Content Team Lead, Knowledge Translation Unit
39
40 University of Cape Town Lung Institute, Knowledge Translation Unit, University of Cape Town,
41 South Africa, Mowbray 7700
42
43 Sandy Picken
44 Senior Content Developer
45
46
47
University of Cape Town Lung Institute, Knowledge Translation Unit, University of Cape Town,
48 South Africa, Mowbray 7700
49 Makhosazana Lungile Simelane
50 Trainer and Implementation Facilitator
51
52
53 King’s Global Health Institute, King’s College London, UK, SE1 9NH
54 Lara Fairall
55
56 Professor of Global Healthcare Delivery
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 Director, Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape
Town, South Africa, Mowbray 7700
1 Associate Professor, Department of Medicine, University of Cape Town, Observatory, 7925
2
3
4
5 Correspondence to:
6
7 Dr Jamie Murdoch
8
9 School of Health Sciences
10 University of East Anglia
11
Edith Cavell Building
12
13 Colney Lane
14 Norwich
15 NR4 7TJ
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17 United Kingdom
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19 Tel: 0044 1603 597090
20 Fax: 0044 1603 597018
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23 Jamie.murdoch@uea.ac.uk
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 Abstract

1 Background: Despite significant reductions in mortality, preventable and treatable conditions

2
3
4 remain leading causes of death and illness in children aged under five in South Africa. The PACK
5
6 Child intervention, comprising a clinical decision support tool (guide), training strategy and health
7
8
9 systems strengthening components, was developed to expand on WHO’s Integrated Management
10
11
12 of Childhood Illness programme, and in 2017-2018 was piloted in 10 primary healthcare facilities in
13
14 the Western Cape Province. Here we report findings from an investigation into the contextual
15
16
17 features of South African primary care that shaped how clinicians delivered the PACK Child
18
19 intervention within clinical consultations.
20
21
22 Methods: Process evaluation using semi-structured interviews, focus groups, observation, audio-
23
24
25
recorded consultations and documentary analysis. Linguistic ethnographic analysis of relationship
26
27 between primary care contextual features and clinician-caregiver interactions.
28
29
30 Results: Primary healthcare facilities demonstrated dominance of a risk minimisation approach
31
32 upheld by provincial documentation, providing curative episodic care to children presenting with
33
34
35 acute symptoms, and preventive care including immunisations, feeding and growth monitoring, all
36
37
38
in children 5 years or younger. Children with chronic illnesses such as asthma rarely received routine
39
40 care. These contextual features constrained the ability of clinicians to use the PACK Child
41
42
43 intervention to facilitate diagnosis of long-term conditions, elicit and manage psychosocial issues,
44
45 and navigate use of the guide alongside provincial documentation.
46
47
48 Conclusion: Our findings provide evidence that PACK Child is catalysing a transition to an approach
49
50 that strikes a balance between risk minimisation on the day of an acute presentation and a larger
51
52
53 remit of care for the child over time. However, to optimise success of the intervention requires
54
55
56 reviewing priorities for paediatric care which will facilitate enhanced skills, knowledge and
57
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59 Page 3 of 45
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 deployment of clinical staff to better address acute illnesses and long-term health conditions of

1 children of all ages, as well as complex psychosocial issues surrounding the child.
2
3
4 Keywords
5
6 Child health; Health systems evaluation; Paediatrics; Prevention strategies; Other study design
7
8
9
10
11 BACKGROUND
12
13 The three principal objectives of the 2016–2030 Global Strategy for Women’s, Children’s and
14
15
16 Adolescents’ Health are Survive, Thrive and Transform, including the need to build resilience in
17
18 health systems, improve the quality of health services and equity in their coverage [1]. These
19
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21 objectives align with the United Nation's Sustainable Development Goals,[2] which envisage the
22
23
24 highest standards of physical and mental well-being for these vulnerable groups. However, large
25
26 inequalities persist in access to and the quality of care in many low and middle-income countries
27
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29 (LMICs)[3]. In South Africa, the management of common childhood illnesses at a primary healthcare
30
31 level remains poor with preventable and treatable conditions, particularly pneumonia and
32
33
34 diarrhoea, remaining the leading causes of death in children under five [4]. With under-five
35
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mortality rate of 42 per 1000 live births in 2015[4], considerable ongoing improvements in health
38
39 worker skills and quality of care are required to reach the Sustainable Development Goal target of
40
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42 less than 25 per 1000 live births by 2030.
43
44
45
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47 Trends in the global burden of disease from 1990 to 2015 show increased rates of chronic NCDs
48
49 across LMICs both for children aged below and above five years[5], calling for interventions that
50
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52 more effectively identify and treat common chronic conditions, for example asthma which globally
53
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55 is the most common long-term health condition in childhood. In South Africa, the prevalence of
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57 asthma is 10% in 6-7 year olds and as high as 15% in 13-14 year olds, and approximately half of
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 affected children have severe uncontrolled symptoms and more than 30% have never been formally

1 diagnosed[6]. Lack of chronic illness management training for nurses and limited access to doctors
2
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4 and equipment in primary health care facilities contribute to this situation, often leading to children
5
6 with long term conditions bypassing these clinics and presenting at secondary level hospitals [7, 8].
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12 The World Health Organizations’ (WHO) Integrated Management of Childhood Illness strategy
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14 (IMCI),[9], was developed to address the top causes of mortality in children under five, and is the
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17 standard of care in over 100 Low- and Middle- Income Countries (LMICs), including South Africa,[10].
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19 A 2010 multi-country review of IMCI,[11] confirmed improvements in prescription accuracy,
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22 treatment and health service quality and a 2016 Cochrane review,[12] found evidence of a reduction
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in neonatal and infant mortality. However, an evaluation of IMCI’s impact since its introduction in
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27 1998 reported variable fidelity to the strategy’s guidance,[13] limited training and ongoing
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30 supervision of primary care workers, (in South Africa usually professional nurses), and infrequent
31
32 updating,[14]. The IMCI strategy also does not address the health needs of children over five years
33
34
35 or those with chronic conditions needing regular follow-up, and requires more complete integration
36
37
38
of curative and preventive measures, including care for the well child. A key conclusion of WHO’s
39
40 2016 strategic review of IMCI stated that “with attention focused on specific child health areas such
41
42
43 as immunization and communicable diseases, a holistic view of child health has arguably been lost
44
45 inside the continuum of reproductive, maternal, newborn, child and adolescent health.”[12, 15]
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48 To help address these gaps, the Knowledge Translation Unit (KTU) developed a paediatric version of
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50 its Practical Approach to Care Kit, (PACK) [16], intervention, comprising of a clinical decision support
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53 tool, training programme, and health system strengthening including enhanced supervision with
54
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56 regular updates as guidance and policies change[17-20]. PACK Child incorporates IMCI content but
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 provides extended clinical guidance for the child older than 5 years (up to age 13), 16 long-term

1 health conditions, an approach to the well child and additional non-life-threatening, yet common
2
3
4 conditions.
5
6
7
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9 The implementation and training elements of PACK Child are modelled on and complement PACK
10
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12 Adult[18], which was trialled and scaled up in South Africa to over 30 000 clinicians in more than
13
14 3500 clinics[21-23],using a systematic, educational outreach training strategy and cascade model of
15
16
17 implementation. PACK is also being implemented in Botswana[24], Brazil[25], Nigeria[26] and
18
19 Ethiopia[27], is available globally through a partnership with BMJ (pack.bmj.com) and is being
20
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22 localised for piloting in China[17].
23
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25
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27 Implementation of a more expanded programme like PACK Child alongside the long-established
28
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30 IMCI raised many legitimate concerns for policymakers, prompting a detailed process evaluation of
31
32 the first pilot of the intervention in the Western Cape Province. These concerns were chiefly around
33
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35 whether, given the structural constraints, it was feasible to extend the scope of paediatric primary
36
37
38
care delivery, and whether PACK Child would augment or undermine other priorities like IMCI, early
39
40 childhood development, growth monitoring and preventive care and appropriate referral patterns.
41
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43
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45 We have already published the protocol and an overview of our findings from the process evaluation
46
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48 [28], which provides important insights regarding how the intervention articulated with the existing
49
50 primary healthcare system over the three phases of the pilot, and the impact on clinical practice
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53 and caregiver perceptions of care. In this paper, we expand on how the organisational and social
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56 context of paediatric primary care influenced implementation of PACK Child, reporting findings from
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 an in-depth qualitative analysis of audio-recorded consultations to demonstrate the relationship

1 between the delivery of PACK Child and the wider social context of paediatric primary care.
2
3
4
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6 Previous research that has observed clinical consultations in LMICs has relied heavily on structured
7
8
9 checklists to assess clinician’s adherence to clinical protocols, and in paediatric consultations the
10
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12 focus has been on clinician adherence to IMCI guidelines [29, 30]. Whilst raising awareness of the
13
14 extent of IMCI implementation, such research has isolated individual clinician performance from the
15
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17 contextual conditions that facilitate or constrain their behaviour, thereby offering limited insight
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19 into how to improve delivery of care. In the study reported here, we attempted to move beyond
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22 individualised explanations of clinician performance by tracing a relationship between the South
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African healthcare system, clinician-caregiver interactions and clinician’s use of documentation,
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27 empirically exposing how the broader context of primary health care shaped the use of PACK Child
28
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30 in clinical consultations.
31
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33
34
35 METHODS
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38
The process evaluation used a linguistic ethnographic,[31, 32] methodology, which combines
39
40 strengths of linguistics and ethnography to systematically investigate human behaviour in context.
41
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43 Linguistic ethnography provides theoretical and methodological tools for analysing how the
44
45 meaning of talk, text and objects shift over time and space. We have previously adapted this
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48 approach [33] to facilitate detailed investigation of complex healthcare interventions across macro-
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50 , meso- and micro-contextual levels, drawing on Bronfenbrenner’s socio-ecological model of
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53 behaviour[34].
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 Mixed methods were used including quantitative and qualitative data collection and analytic

1 approaches, with all methods described in our overview paper. In this paper, we provide a detailed
2
3
4 report of findings from the qualitative analysis of our observations of non-clinical areas, observed
5
6 and audio-recorded consultations, documents and interviews with primary healthcare (PHC) facility
7
8
9 managers, senior paediatric managers and policymakers.
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12
13
14 Research Setting
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17 The setting for this pilot and process evaluation was 10 public- sector PHC facilities serving
18
19 impoverished urban and rural communities in the Western Cape province, South Africa. Child health
20
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22 services within PHC facilities are provided for children aged 0-13 years. Phase One took place in a
23
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25
single facility, Phase Two in an additional three facilities and Phase Three in a further six facilities.
26
27 The facilities were purposively selected to provide maximum variation of primary care delivery in
28
29
30 partnership with the Western Cape Health Department’s People Development Centre, which
31
32 oversees training and upskilling of public sector healthcare workers in the Western Cape. See Curran
33
34
35 et al. [28] for full details of facility characteristics and sampling strategy.
36
37
38
39
40 Data collection
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43 To understand the macro-contextual features shaping delivery of the PACK Child intervention,
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45 interviews were conducted with managers at each PHC facility, and a stakeholder focus group with
46
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48 senior paediatric managers, policymakers and clinicians. Facility managers were asked about staff
49
50 resource allocation to paediatric care, relevant policies, patient flow and perceptions of the PACK
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53 Child intervention for supporting the care of children. Senior paediatric managers and policymakers
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56 were asked about challenges of the current healthcare system and how they viewed the role of
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 PACK Child in helping to address those challenges. We also conducted a documentary analysis of

1 the structure and content of 1. The PACK Child guide, 2. The IMCI guide and checklist, 3. Integrated
2
3
4 Clinical Stationery and 4. The Road to Health Booklet (old version) [35] to understand how the
5
6 broader principles underpinning these different texts are operationalised to deliver paediatric
7
8
9 primary care (see Table 1 and Additional files 1-4).
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11
12
13
14 To understand the meso-contextual features shaping delivery of PACK Child, we drew on the PHC
15
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17 facility manager interviews, in conjunction with observations of waiting room and reception areas
18
19 to understand the flow of patients through the facility. Using a qualitative observational framework,
20
21
22 (see Additional file 5), the researcher recorded field notes of their observations of how children
23
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25
accessed care within facilities, from reception to different clinicians/providers.
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30 To understand how clinician’s use of PACK Child articulated with micro-contextual features of
31
32 paediatric primary care we conducted observations and audio-recordings of clinical consultations
33
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35 with children and caregivers in each of the pilot facilities. Consultations were conducted in the
36
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38
language or languages the caregiver, child and clinician were most comfortable communicating in.
39
40 Recordings of consultations conducted in Afrikaans and isiXhosa were translated and transcribed in
41
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43 English. A researcher (RC or JM) was present in the consultation room at the time of recording in
44
45 order to observe and document how clinicians used PACK Child and other documentation during
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48 the consultation, as well as other relevant non-verbal behaviour which contributed to
49
50 understanding the consultation.
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 The PACK Child Intervention

1 The PACK Child guide, which is aligned with recognised standards for guideline development,[36,
2
3
4 37] is an evidence–informed, policy-aligned integrated clinical decision support tool, including
5
6 algorithms that facilitate identification of likely diagnoses. The guide is designed to be adapted to
7
8
9 LMICs globally, covering 63 common symptoms, including IMCI components such as diarrhoea and
10
11
12 pneumonia, but importantly, it extends the scope of IMCI by focusing on children 0-13 years. It is
13
14 also designed to address 16 long-term health conditions most commonly seen in primary care, as
15
16
17 well as including a comprehensive approach to screening the well child. Routine care of the well
18
19 child (see Additional file 1) includes measuring and interpreting growth, screening developmental
20
21
22 milestones, checking immunisations, deworming, vitamin A, TB and HIV screening, as well as asking
23
24
25
about the mental health of the child or problems in school. It also encompasses an assessment of
26
27 the carer’s health including screening for psychosocial risk factors such as depression, violence in
28
29
30 the home or financial difficulties. Routine care is intended to be sequenced after establishing the
31
32 need for urgent care for the presenting symptom, but before definitive care for non-urgent
33
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35 symptoms. Clarity around clinician scope is provided with medications colour-coded according to
36
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38
prescriber. Designed to promote the continuum of care required to break the acute episodic care
39
40 cycle, the guide prompts routine care into every consultation. Its content reinforces the messaging
41
42
43 of existing initiatives like the Road to Health Booklet Side-By-Side messaging, the First 1000 Days
44
45 initiative and the Nurturing Care framework.
46
47
48
49
50 Drawing on the successful PACK Adult training methodology, the PACK Child training programme
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53 used an onsite in-service cascade model (see Additional file 6) to be delivered in three phases for
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56 the pilot[19]. The first phase included one facility trained by a KTU trainer, the second phase
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 included three facilities trained by two KTU trainers and the third phase conducted at six facilities

1 was rolled out two by PACK Child Facility Trainers - government employees trained into the role by
2
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4 KTU during a five-day off-site workshop. The training included eight onsite training sessions
5
6 delivered weekly in the PHC facilities; this was expanded to nine during phase two of the pilot to
7
8
9 include a “health systems session” focusing on patient flow and distribution of tasks among cadres
10
11
12 in contact with children. The training was designed to target all cadres of clinicians at facilities,
13
14 mainly nurses and doctors and emphasises the alignment of the PACK Child content to IMCI,
15
16
17 integration of care for the child’s caregiver using PACK Adult, and upskilling of all clinical staff to
18
19 encourage a multi-disciplinary approach to paediatric primary care.
20
21
22
23
24
25
During the course of the pilot, bi-weekly meetings were scheduled to feedback on the content of
26
27 the guide and issues with implementation in practice. This provided a regular opportunity to
28
29
30 capture further refinements and clarifications in the PACK Child guide and for the training
31
32 development. One of the content developers attended the training sessions in the first phase to
33
34
35 ensure the usability of the guide and identify challenges within the primary care setting.
36
37
38
39
40 Eligibility and Sampling
41
42 To be eligible for inclusion in the study, nurses and doctors needed to receive PACK Child training,
43
44
45 and caregivers and children aged birth to 13 years needed to be receiving paediatric services at the
46
47
48 selected facilities. Policymakers needed to be responsible for delivery of primary care in public
49
50 sector PHC facilities.
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53
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55 Sampling of children for consultation observations was dependent on which children presented at
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 the facility on the day of data collection, with nurses identifying and approaching suitable

1 participants in the waiting room areas. However, the limited number of children in Phase One who
2
3
4 had a chronic condition or were older than five years informed identification and inclusion of these
5
6 children Phases Two and Three. Similarly, the inclusion of only nurses in Phase One informed a
7
8
9 proactive attempt to include doctors in Phases 2 and 3.
10
11
12
13
14 Ethics
15
16
17 Ethics approval was obtained from University of Cape Town Human Research Ethics Committee, City
18
19 of Cape Town Research Ethics Committee and the Western Cape Provincial Health Research
20
21
22 Committee. Full details of our sampling strategy and ethical considerations are provided in Curran
23
24
25
et al [28].
26
27
28
29
30 Data Analysis
31
32 To understand how PHCs were organised to provide child care, and the interaction between
33
34
35 contextual features and intervention delivery, we firstly analysed manager and policymaker
36
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38
interview data, and field notes of our observations of waiting rooms and reception areas. All
39
40 interviews were transcribed verbatim and thematically analysed. Themes and field notes from
41
42
43 observations of waiting room areas were compared to identify and describe similarities and
44
45 differences in the organisation and flow of patients across facilities. Secondly, we analysed the
46
47
48 audio-recordings, transcriptions and researcher field notes of consultations to understand how
49
50 macro- and meso-contextual features shaped, and were shaped by nurse’s interactions with
51
52
53 caregivers and children. A key focus was to identify instances of how use of PACK Child aligned
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 with routine practice, providing “telling cases”,[38] of the wider social forces structuring

1 intervention delivery at the point of delivery.

2
3
4
5
6 Audio recordings of consultations were transcribed verbatim. A sub-sample was transcribed using
7
8
9 conversation analytic conventions,[39, 40] to provide detailed evidence of how clinician’s use of
10
11
12 the PACK Child guide was negotiated within interactions with caregivers and children. We then
13
14 inductively coded each transcript by activity, for example “eliciting the child’s presenting
15
16
17 problem”, “physical examination”, or “advice giving”. We cross-referenced these against the field
18
19 notes of the researcher’s observations to determine what documentation, if any, was used during
20
21
22 each activity. This enabled us to obtain a broad picture of the structure of consultations within
23
24
25
and between clinicians and facilities. We then coded clinician’s questions according to their
26
27 function as part of the clinical assessment process (e.g. asking about presenting complaint, wider
28
29
30 information gathering) and the structural form of the question (e.g. polarised, content or
31
32 alternative question). This enabled us to understand patterns of questioning within each activity
33
34
35 and the role of PACK Child and other documentation in shaping clinicians’ questioning. Using data
36
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38
collected during Phase One, one researcher (RC) completed all the coding of activities and
39
40 questions and a second (JM) independently coded a sample 10% of the data. A Kappa score was
41
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43 calculated in a first round of question coding (0.72-0.83). Disagreements in coding and coding
44
45 categories were discussed, refined and then second round of coding for a further 10% of questions
46
47
48 conducted, revealing a high level of agreement (0.92-0.94). Finally we interrogated each transcript
49
50 to understand the consequences of the consultation structure and question-response sequences
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53 for the ongoing interaction, how the clinician’s use of the PACK Child guide influenced the
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56 direction of the consultation, and how this use interacted with the use of other documentation.
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 1 Data synthesis
2
3
4 The analysis of qualitative data was iterative, moving between data collection and analysis to test
5
6 emerging theories, comparing how managers’ views related to actual implementation of primary
7
8
9 care and use of PACK Child. For example, managers reported particular facility processes or
10
11
12 protocols that we then compared with our observations of waiting room areas and clinical
13
14 consultations. Instances of how PACK Child aligned with routine practice within consultations
15
16
17 provided insight into the tensions between different contextual features which we could then
18
19 investigate further in subsequent observations and triangulate with data obtained from manager
20
21
22 interviews.
23
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25
26
27 The synthesised data were then used to map macro-, meso- and micro-contextual features with a
28
29
30 consideration of how national policy at a macro level impacted on the organisation and skill mix of
31
32 staff at a meso level, and then ultimately how care was delivered to children at a micro level within
33
34
35 consultations. By focusing on (mis)alignments to implementation and setting the PACK Child
36
37
38
intervention within a contextual framework, we were able to make the transition from the
39
40 identification of patterns of PACK Child use in specific facilities, to theoretical explanations of how
41
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43 different structural relations and mechanisms organise moments of delivery, facilitating
44
45 generalisable inferences and predictions on how to optimize PACK Child for future implementation.
46
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48
49
50 RESULTS
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53 We conducted ten facility manager interviews (one per facility); one focus group with 24
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56 stakeholders including clinicians, policymakers and senior paediatric managers; ten observations
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 (one per facility) of waiting room and reception areas; and 53 observations with audio-recordings

1 of clinical consultations with children and caregivers, (Phase 1 = 16; Phase 2 = 13; Phase 3 = 24),
2
3
4 totalling 18 hours and generating 595 pages of transcripts. Forty consultations were conducted in
5
6 English, eight in Afrikaans and five in isiXhosa. In Phase One, observations were interspersed
7
8
9 between the eight PACK Child training sessions. Our analysis of these data identified clinicians
10
11
12 reading aloud from the guide during consultations and difficulties using the guide alongside other
13
14 medical documentation. This insight highlighted the importance of allowing time for clinicians to
15
16
17 practise using the PACK Child guide and informed theoretical sampling of further observations in
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19 Phase Two and Three, which we timed to be conducted once the PACK Child training sessions had
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21
22 been completed at facilities. Following the high proportion of children presenting with acute
23
24
25
infections in Phase One, we also attempted to sample children presenting with chronic conditions
26
27 in Phases Two and Three. In Phase Three, one child with asthma and nine with eczema were
28
29
30 included.
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35 First we report how macro-, meso- and micro-contextual features of paediatric primary care had an
36
37
38
impact on the integration of PACK Child at the point of delivery within consultations. In Tables 1 and
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40 2 we have set out the macro and meso elements of context, with illustrative quotes from facility
41
42
43 manager interviews. We then present extracts from the audio-recorded consultations, providing
44
45 telling cases of how macro- and meso-contextual features were made salient by clinicians at a micro-
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47
48 contextual level, specifically in terms of how they used the PACK Child guide alongside other
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50 documentation and how they interacted with children and caregivers.
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 Insert Table 1

1
2 Insert Table 2
3
4
5 Following the introduction of PACK Child within this social and organisational context, nursing staff
6
7
8 reported immediate benefits of the training and guide for supporting their management of children,
9
10 particularly with regard to improving growth monitoring, enhanced knowledge of how to manage
11
12
13 conditions not covered by IMCI and reduction in unnecessary referrals. We have reported details of
14
15
16 those findings in our overview publication [28]. The findings reported here focus on the interaction
17
18 between a health system geared towards preventive care and management of acute illnesses in
19
20
21 under fives with the more comprehensive view taken by PACK Child. A particular challenge was how
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23 clinicians worked to incorporate the training and guide alongside pre-existing practice, while
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26 complying with provincial requirements to complete IMCI checklists and in half of the facilities, new
27
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29
Integrated Care Stationery for auditing the clinical management of children aged under five. Figure
30
31 1 is an extract of observational field notes recorded by a researcher over a three-hour period
32
33
34 observing a facility waiting room area during Phase One. The diagram shows lines of benches, three
35
36 consulting rooms, a triage area staffed by enrolled nurses and a breastfeeding corner. The field
37
38
39 notes report a two-hour period of observing the triage desk. Triage commenced three hours after
40
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42
caregivers and children arrived at the facility, following delays in retrieving the child’s medical notes.
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44 Children presented as well or with acute symptoms, typically a rash, sore throat or fever. Children
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47 were weighed at the triage desk. The enrolled nurse did not plot the weight or interpret the growth
48
49 of the child. Once caregivers had answered the same three questions (i.e. age, weight, problem)
50
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52 there was no further clinical assessment until their consultation with a nurse. These field notes
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54 represent a broader pattern we observed, of caregivers attending facilities with children aged 0-5
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57 years when they had acute symptoms, or needed immunisations and their growth monitoring; and
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 PHC facilities predominantly oriented to deploying nursing staff to consult and treat children’s

1 symptoms as discrete episodes with little consideration of the child’s long-term health needs. When
2
3
4 interviewed about their child’s condition, a number of caregivers also reported how they had
5
6 repeatedly attended their facility when symptoms worsened, and that the symptoms were routinely
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9 treated as a series of isolated incidents[28].
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12
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14 Figure 1: Observation of waiting room, triage and reception area
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36 The impact of the organisational context on the use of PACK Child during consultations
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38
Table 3 provides a breakdown of the characteristics of the clinicians and children participating in
39
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41 consultation observations where PACK Child was used. We now examine how the macro- and meso-
42
43
44 contextual features impacted on clinician-caregiver-child interactions. In doing so, we are observing
45
46 an interaction at a micro-contextual level, between the approach of PACK Child with a focus on
47
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49 children aged 0-13 years covering acute and long-term health conditions and screening of the well
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51 child, and the existing healthcare system where IMCI and RtHB policies are embedded, and ICS is
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54 being introduced.
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 Table 3: Characteristics of clinicians and children participating in consultation observations

1 Characteristic Total across pilot

2
3 Clinical Nurse Practitioner 17
4
5 Professional Nurse 11
6 Cadre of Staff
7 Doctor 3
8
Enrolled Nurse 2
9
10
11
12 < 2 months 3
13
14 Age ranges of children 2 months-5 years 37
15
5 years and above 13
16
17
18
19 Rash 14
20
21 Tight Chest 1
22
Upper Respiratory Symptoms 6
23
24 Gastro-Intestinal Symptoms 5
25
26 Cough 7
27
28 Reason for Visit Eye Symptom 2
29
30 Headache 1
31 Immunisation and growth monitoring (well child visit) 7
32
33 Asthma 1
34
35 Eczema 8
36
37 Injury 1
38
39
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41 Clinical assessment questions
42
43
44
In our sample of 53 audio-recorded consultations we identified and coded 1218 clinical assessment
45
46 questions. Table 4 displays four important features about the nature of these questions in our
47
48
49 sample. Firstly, the three highest number of question types were oriented to topics required by IMCI
50
51 – acute symptom management (wider information gathering and reported complaint) and growth
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53
54 monitoring, immunisations and questions about feeding, making up 56% of all questions. This partly
55
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reflects the characteristics of our sample with 37 out of 53 children presenting with acute physical
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 symptoms but also reveals the orientation to IMCI and risk minimisation policy within consultations.

1 Secondly, 84% of psychosocial questions were delivered as polar questions, with only 14% delivered
2
3
4 as content questions (i.e. questions with “what”, “where”, “why”, “how” formulations). Polar
5
6 questions [42] are questions that are either interrogative or declarative and are designed to prefer
7
8
9 either a “yes” or “no” response. In the process of clinical assessment, clinicians’ use of polar
10
11
12 questions have also been shown to frequently prefer no problem answers [33, 43]. For example,
13
14 “And she is weeing ok?” is a declarative question designed to prefer a yes and rule out dehydration,
15
16
17 whilst the inclusion of “at all” tilts the interrogative “Has she vomited at all?” to prefer a no and the
18
19 absence of vomiting. Applying this to questions designed to elicit potentially sensitive psychosocial
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21
22 issues, the high proportion of polar questions relative to content questions suggests that clinicians
23
24
25
did not design questions which invited disclosure of psychosocial problems around the child. Thirdly,
26
27 the number of questions about long-term health conditions (other than TB and HIV), located in 18
28
29
30 out of the 53 consultations shows that clinicians sometimes identified symptoms as markers of
31
32 potential chronic conditions, prompted by the routine care and long-term condition pages within
33
34
35 the PACK Child guide. Questions included those aimed at determining if the child had an allergy,
36
37
38
asthma, mental health or behavioural difficulties. Finally, we identified only six questions that
39
40 elicited the caregivers’ concerns, ideas or expectations and only nine questions that assessed past
41
42
43 medical care (excluding TB and HIV). While the PACK Child intervention does not specifically prompt
44
45 clinicians to elicit caregiver’s perspectives, this finding suggests that the clinicians in our sample did
46
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48 not habitually ask questions that attempted to gain a picture of the child beyond the specific
49
50 problem presented on the day.
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 Taken together, these different features of clinical assessment questions indicate that clinicians

1 were working in a transitional space between an institutionalised practice of episodic risk

2
3
4 minimisation on the day to risk minimisation over time. The challenge in making this transition is
5
6 most clearly seen in the use of polar questions to elicit psychosocial issues. Rather than viewing the
7
8
9 predominance of polar questions designed to limit disclosure of psychosocial issues as a failure of
10
11
12 nurse performance, we can see these questions as a manifestation of the wider healthcare system
13
14 in which they were operating. Working within an everyday context where large numbers of children
15
16
17 from impoverished backgrounds with high rates of adversity present with acute symptoms that
18
19 clinicians need to assess for risk, monitor growth, check immunisations and feeding in busy, time-
20
21
22 constrained consultations with limited confidential spaces and referral resources, it is unsurprising
23
24
25
that nurses adopted to phrase these questions in such a way that it limited the possibility of
26
27 disclosure of sensitive psychosocial problems.
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 Table 4. Clinician question coding by type and structural form

1 Structural form of Question

2 Question Type Question Number of Polar N (%) Content N (%) Alternative Total
3 Example consultations N (%) N (%) N (%)
4
5 Wider "Any symptoms 41 (77) 194 (77) 50 (20) 7 (3) 251
6 information that you are
7 gathering having concerns
8 about, besides
9 his skin now?"
10 Assessing "So you are no 37 (70) 165 (69) 69 (29) 6 (3) 240
11 feeding/growth longer
12 monitoring/ breastfeeding?”
13
immunisations
14
15 Asking about “Coughing for 45 (85) 119 (61) 67 (34) 9 (5) 195
16 reported how many
17 complaint days?”
18 Eliciting “And you do you 29 (55) 143 (84) 24 (14) 4 (2) 171
19
psychosocial have support
20
issues from the child’s
21
22 father?”
23 Asking about HIV “Have you tested 36 (68) 95 (71) 32 (24) 7 (5) 134
24 or TB for HIV when you
25 were pregnant?”
26
Asking about “What tablet did 31 (58) 86 (72) 27 (23) 7 (6) 120
27
28 treatments you give?”
29 Asking about "Is he a known 18 (34) 50 (89) 6 (11) 0 (0) 56
30 other long term asthmatic?"
31 health conditions
32
Asking about “And you 19 (36) 26 (72) 9 (25) 1 (3) 36
33
34 family planning yourself are you
35 on any family
36 planning
37 mommy?”
38 Assessing past “So the child 7 (13) 6 (67) 2 (22) 1 (11) 9
39 medical care hasn't been
40 other than TB/HIV treated at any
41 other institution
42
before for
43
44 anything, for this
45 problem?”
46 Eliciting caregiver “Is there 5 (9) 6 (100) 0 (0) 0 (0) 6
47 concerns, ideas, anything that
48 expectations you would like to
49 ask?”
50
51 Total 890 286 42 1218
52 Notes: This table shows the number and proportion of consultations for each question type in the sample of observed
53 consultations. It also shows the number and proportion of different structures within each question type. Polar questions prefer a
54 yes or no response. Content questions (or Wh- questions) are open questions inviting new information whereas alternative
55 questions present two or more options embedded in the question. Proportion of consultations is a percentage of all 53
56 consultations. Proportion of polar, content and alternative questions are percentages within each question type category.
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 Introducing the PACK Child guide into routine consultations

1 In our overview paper [28], we reported how clinicians could be seen frequently switching between
2
3
4 different routine care and symptom-based activities and various sections of the PACK Child guide,
5
6 whilst also completing necessary documentation. An issue for the delivery of PACK Child
7
8
9 consultations is how this fragmented distribution of activities, and constant switching between
10
11
12 other activities and documentation, occurred during the interactions between clinicians, caregivers
13
14 and children. The extract in Box 1 provides a “telling case” of this fragmented distribution[38], taken
15
16
17 from a consultation conducted in one of the facilities participating in Phase Three of the study, which
18
19 involved a nurse using PACK Child to manage and treat a three-year-old child presenting with a
20
21
22 cough.
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 Box 1: Nurse navigating PACK Child with IMCI checklist and RtHB
Consultation from a Phase 3 PHC facility with a mother and three-year-old girl presenting with a cough she has had
1 for three days. The nurse begins the consultation using the IMCI checklist where she documents the cough as the
2
3
presenting symptom, enquires about the presence of diarrhoea and the caregiver shows the nurse the child’s skin
4 rash. The extract begins after 2 minutes into the consultation.
5 Nurse (N) Nurse of caregiver talk Use of PACK Child guide, IMCI
6 or :: Elongated vowel checklist and RtHB
7 Caregiver [ ] Overlapping talk
8 (CG) (1) Timed pause, (.) less than 1 second.
9 
Hearably quieter speech
10 CAPITALS denotes hearably louder speech
11 Underlined talk indicates spoken with emphasis
12
Heh heh denotes laughter
13
14 (( )) Further information
15 N O::kay a::nd uh (.) feeling hot at night? Or during the day? N writing on IMCI checklist under
16 “Fever” Yes or No
17 (1.0)
18 CG [No::]
19 N [No] okay and u::m (.) can I see your hand and the babies hand? I am going N checking ‘Anaemia’ on IMCI
20
21 to try to be quick checklist
22 (??)
23 N Okay thank you. An::y (.) what is your HIV status Si:si::? ((Sister in isiXhosa)) N working through IMCI checklist
24 “Consider HIV infection”
25 CG [Negative]
26 N [Your HIV]? Negative
27
CG Huh
28
29 N When, when did you, whe:n did you?
30 CG You are the one who did la:st month.
31 N Heh heh heh [heh heh heh] ((Nurse realises she forgot that CG has already
32 taken HIV test))
33 CG [Heh heh heh] When I come with ((name of child))
34
N Okay. O::kay. U:H How old is this baby FIRST?
35
36 CG She is two years three mo:nths N opens PACK Child to content
37 page
38 (3.0) N looks at RtHB
39 N O::kay, we go to a content page which is u::h page um (2) u::hm 50 for cough N opens PACK Child routine care
40 and also we go for routine care which is page u:h 14. She is, how old is she page to check what she needed to
41 now? do.
42 CG Two:: yea::rs
43
44 N Mmm
45 CG A:nd three months
46 N Two years and thre:e months. Two years is here, we must check the weight. N reading from routine care page
47 Let's see the weight, the weight is 16 and where is he:r card? Is here ((child N searching for RtHB
48 coughs)). HAIBO ((surprised expression in isiXhosa)) SISI you are coughing ne:
49 ((Afrikaans particle word meaning “isn’t that so” used for emphasis))
50 CG Mm
51
N 16 point (.) plot the wei::ght. 16 point 6. She is two years a::nd? N plotting weight in RtHB
52
53 CG Three months.
54 N And three mo::nths (1) March April May June Ju:ly (2) and is 16 point six (2) N showing CG that child is growing
55 hmm (12.0) sixteen (.) which is 16 point 6 (.) Yoh! She is growing very well ne well.
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 The transcript of this consultation shows the predominance of different medical documents and

1 guidelines which clinicians had to navigate within the consultations, in this case the IMCI checklist,
2
3
4 RtHB and PACK Child guide. Following a question about the duration of the child’s cough, the extract
5
6 begins with the nurse using the IMCI checklist to complete three tasks, asking about the child’s
7
8
9 temperature, examining the child’s hands and checking the mother’s HIV status. For each of these
10
11
12 tasks we can see how the IMCI checklist plays a key role in steering the nurse questioning and
13
14 sequence of activities within the consultation. At two minutes and 47 seconds, and after completing
15
16
17 the IMCI checklist, the nurse opens the PACK Child guide for the first time whilst also referring to
18
19 the RtHB. The nurse identifies which page in the guide deals with coughs but also the routine care
20
21
22 page, where each PACK Child consultation is intended to begin. The nurse selects the routine care
23
24
25
page and checks what needs to be covered in the consultation. Prompted to check the child’s weight
26
27 the nurse then searches for the RtHB and plots the child’s weight as required.
28
29
30
31
32 Following the end of this extract the nurse then continues to check items prompted on the PACK
33
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35 Child routine care page, including TB risk, immunisation status, vitamin A and deworming. After
36
37
38
completing these tasks at 10 minutes and 30 seconds, the nurse states that “we are going to the
39
40 real problem now” and turns to page 50 in the guide to address the child’s cough. The numerous
41
42
43 pauses in this extract, elongated vowels by the nurse and the sound of the nurse searching for
44
45 different pages (as heard on the recording), indicate the work the nurse is doing to navigate and
46
47
48 complete all three documents and demonstrate the central role of documentation within paediatric
49
50 consultations.
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 While this extract clearly shows the burden of documentation within paediatric consultations, it also

1 reveals a broader tension between IMCI policy, oriented to acute episodic care, and PACK Child
2
3
4 which is attempting to embed routine care into every consultation, with a view to longer term care
5
6 over time. As we have argued, these broader policy and institutionalised tensions play out a micro-
7
8
9 contextual level within clinician-caregiver interactions, offering explanations that go beyond a focus
10
11
12 solely on individual clinician’s competency.
13
14
15
16
17 Responding to and managing long-term conditions
18
19 In assessing clinicians’ ability to use PACK Child to facilitate diagnosis and management of long term
20
21
22 health conditions, an important task was how clinicians responded when conditions or psychosocial
23
24
25
problems were identified. Boxes Two and Three contain extracts from two consultations conducted
26
27 in Phase 3 facilities; telling cases which provide insight into how macro- and meso- contextual
28
29
30 features constrained or enabled clinicians to respond to the needs of children.
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 Box 2. Negotiating caregiver report of behavioural and family problems

1 In a Phase 3 facility a 12-year-old boy presents for an appointment with an ear problem. During the
2 consultation the caregiver voluntarily discloses that the child has a history of Fetal Alcohol syndrome, takes
3
Ritalin for behavioural problems (implying likely involvement of tertiary service because of limited access to
4
5 Ritalin), and has a difficult relationship with a largely absent mother. Despite evidence that the nurse is
6 listening to the caregiver’s concerns about family life, the nurse does not discuss the child’s use of tertiary or
7 social services and she does not refer to the PACK Child guide which includes pages on how to manage
8
9
behaviour and anger problems as well as potential child abuse.
10
11 Nurse (N) or Nurse/caregiver talk Use of PACK Child
12 Caregiver (CG)  High pitch
13 Underline – spoken with emphasis
14 […] sequence of consultation not included
15 N: Is is his own mother still involved in his life? Opens to contents page
16
17 (0.7)
18 CG: Noo::
19 N: [She doesn’t…]
20
21 CG: [She’s her father] is her father is raising two kids of hers those two are
22 working now. (1) Her father is also a FAS ((Fetal Alcohol Syndrome)) baby
23 (1) I say every father gets his packet.
24 N: Mhm
25 CG: They gave him she had tw::o, three children minimum, by a gu:y, two boys
26
and a a girl and she dropped the children by the father and she left (1)
27
28 she’s now she is a year gone from there now.
29 N: Mhm
30 CG: And here he is if she comes she just come and then he fights with her (1.5)
31 because she pu::lls him and they’ve got that anger. And and I tell her she
32 mustn't pull him because he don’t like people to pull him around, and she
33
got a habit of that ‘Kom met my saam’, ‘come with me now’, you know?
34
(1.5) so many times and I told him, ‘you mustn't fight with a mother’ that
35
36 is still your mom (1) irrespective.
37 (1.5)
38 N: So you said he is got sore throat?
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 Box 3. Using PACK Child to make a transition from acute symptom to chronic illness management

1 In a Phase 3 facility a four-year-old girl reports to the clinic with a cough, recurrent wheeze and at the
2 beginning of the consultation the mother reports that the child has asthma. The child was nebulised before
3
the consultation, and no wheeze is heard on auscultation by the nurse. The expected route through the
4
5 PACK Child guide would be to start with the routine care page for every visit, then refer to the wheeze
6 symptoms page to manage acute symptoms, finishing with the asthma routine care in the long-term health
7 condition section.
8
9 The clinical nurse practitioner initially refers to the cough page in the PACK Child guide and then navigates
10
11 to the recurrent wheeze page. She diagnoses the child with allergic rhinitis and prescribes a nasal spray and
12 cetirizine. The mother reports having enough “pumps” but the nurse doesn’t clarify what this includes and
13 prescribes budesonide metered dose inhaler, advising the caregiver that it needs to be taken twice a day
14 and Ventolin (salbutamol) used when necessary. The nurse only briefly refers to the asthma routine care
15
16 page and does not ask the caregiver about the child’s history of exacerbations or hospitalisations.
17 However, following PACK Child the nurse advises the caregiver to book a review appointment in three
18 months.
19
20 Nurse/caregiver talk Use of PC guide
21
22 (…) unclear talk
23 CG She is asthmatic, she comes here for oxygen. I do put her on the nebulizer
24 at home, but it doesn't actually help, because she was coughing all week. I
25
26 had her on the nebulizer last night, but then this morning I told her it would
27 be better if I bring her for the oxygen. They did examine her, they gave her
28 a dosage. So they gave her one this morning. Like the cough just didn’t want
29 to go away
30
31 (…)
32 N Okay, the mom is complaining of a cough, so I go to the contents page.
33
34 CG (…) She’s forever chesty (...).
35 N The child with breathing problems may have noisy breathing, wheeze. Did Checking PC cough page
36
she have a wheeze this morning, before they nebulized her?
37
38 CG Last night they nebulized her.
39
N And this morning I saw that they gave her a nebulizer?
40
41 CG Umm no, no::t this morning. Probably they gave her oxygen, yes.
42 N But it’s a nebulizer.
43
44 CG Okay
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 The extract in Box Two demonstrates a lack of information provided by tertiary or social services

1 surrounding the child’s behaviour and problems with his parents, with the nurse needing to decide
2
3
4 how to respond within the constraints of a time-limited consultation which also required her to
5
6 tackle the child’s sore throat symptoms. Despite the availability of pages within PACK Child that
7
8
9 guide the clinician on how to manage symptoms of behaviour, anger and abuse, thereby offering
10
11
12 the opportunity for the nurse to support continuity of care between primary and tertiary services,
13
14 the nurse instead redirects the focus from a complex set of psychosocial issues back to the acute
15
16
17 physical symptom.
18
19
20
21
22 In contrast, the extract in Box Three illustrates a nurse operating in the transitional space between
23
24
25
a health care system structured to focus on treating acute symptoms and PACK Child that supports
26
27 ongoing care of long-term conditions. The clinical nurse practitioner, using the PACK Child guide is
28
29
30 able to prescribe an inhaled corticosteroid for asthma, successfully diagnose comorbid allergic
31
32 rhinitis, and books a follow-up appointment for the child. However, the nurse doesn’t explore which
33
34
35 inhalers the child is already using, follow the guide as instructed in the training programme, or ask
36
37
38
questions about previous exacerbations or hospitalisations.
39
40
41
42
43 DISCUSSION
44
45 The PACK Child intervention was developed to address the limitations of IMCI in tackling
46
47
48 preventable and treatable conditions in children, expanding a focus from under-fives to children
49
50 aged up to 13 years and those living with long term health conditions. However, implementation of
51
52
53 PACK Child needs to take place within a primary healthcare system that primarily deploys
54
55
56 professional nurses focusing on conditions covered by IMCI, and restricts nurse prescribing for
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 common long-term health conditions like asthma and eczema. This presents a number of challenges

1 for how best to embed an intervention into routine practice that aims to provide more holistic care
2
3
4 across age groups, a spectrum of acute and chronic conditions and constellations of clinical and
5
6 psychosocial needs. The mapping of macro- and meso-contextual features, observation of patient
7
8
9 flow within waiting room areas, the profile of patients within our sample and the analysis of
10
11
12 consultations provided insight into how these challenges are rooted in primary care facilities that
13
14 are institutionalised to receive and treat children 0-5 years, predominantly for acute symptoms, to
15
16
17 monitor growth and ensure immunisations are up to date.
18
19
20
21
22
23 A key finding reported in our overview paper was that clinicians across our sample struggled to
24
25 integrate the use of PACK Child alongside either the IMCI checklist, ICS and RtHB, producing
26
27
28 disjointed consultation structures. The extracts from clinical consultations presented within this
29
30 article offer further insight into this finding, highlighting that caution should be exercised when
31
32
33 asking clinicians to manage different documentation within consultations. However, to focus solely
34
35
36 on the difficulties of managing documentation within consultations would be to reduce the
37
38 interpretation of findings to individual clinician performance, thereby isolating the clinician’s
39
40
41 behaviour from the wider healthcare system in which that performance is structured and brought
42
43 into action. A more important conclusion to be taken from the extracts we have reported here is
44
45
46 that they reveal tensions between broader policies that are invoked by clinicians when using these
47
48
49
different documentation in their interactions with caregivers and children. Firstly, the IMCI checklist
50
51 was designed to operationalise a risk minimisation policy aimed at tackling the leading causes of
52
53
54 child mortality. The clinician must record information primarily using tick boxes that inevitably drive
55
56 the design and sequencing of clinical assessment questions to rule out the presence of life-
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 threatening conditions. Secondly the ICS, which incorporates IMCI risk minimisation components,

1 represents an extension of IMCI to provide continuity of documentation, using columns to track

2
3
4 previous visits. It was also designed to complement PACK Child, with space to record a range of long-
5
6 term conditions, to support ongoing routine care of children 0-5 years (a separate form for children
7
8
9 aged over six years), as well as addressing the psychosocial context and risks surrounding the child.
10
11
12 The PACK Child guide and ICS are therefore documents that embody a broader agenda to tackle a
13
14 perceived absence in the continuity of information for children, an assessment of progress of the
15
16
17 child over time and the importance of tracking long-term health conditions as the child develops. A
18
19 different approach to the consultation is therefore required, utilising questions that orientate more
20
21
22 closely to facilitating diagnosis of underlying conditions, track the child’s medical history and enable
23
24
25
disclosure of potentially sensitive psychosocial issues. Finally, the RtHB is also designed on a
26
27 principle of ensuring continuity of information including growth monitoring charts, largely
28
29
30 duplicating information within the IMCI and ICS documents to be kept by the caregiver.
31
32
33
34
35 The clinician, when using these different documents in one consultation is therefore navigating
36
37
38
his/her way through these different policies recontextualised at a micro-level into different
39
40 consultation structures and question formats which may not be neatly aligned. The interactions we
41
42
43 observed are therefore manifestations of these misalignments, including clinicians using polar-
44
45 declarative questions to elicit psychosocial issues, avoiding difficult social problems in favour of
46
47
48 acute physical symptoms, and interactions that display clinicians attempting to make a transition
49
50 from a focus on symptoms as discrete episodes to underlying conditions that need to tracked and
51
52
53 managed over time. The point being made here is that whilst streamlining documentation is
54
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56 important for enhancing the potential for comprehensive care, it needs to be supported by a
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 healthcare system that is structured to minimise risk and support wellness of children and families

1 over time alongside a risk minimisation policy for acute illness episodes.
2
3
4
5
6
7 Optimising the implementation of PACK Child
8
9
10 By investigating the use of PACK Child within a broader contextual framework we were able to
11
12 develop hypothetical propositions for optimising the implementation of PACK Child on a wider-
13
14
15 scale. Importantly, and in contrast to previous observational research of paediatric primary care in
16
17
18
LMICs[29, 30], this approach facilitates the generation of strategies for strengthening the healthcare
19
20 system that may greatly enhance the impact of training and the practice of clinicians within
21
22
23 paediatric consultations.
24
25
26
27
28 At a macro level, our evidence strongly suggests that the current paediatric care offering urgently
29
30 needs revising to facilitate enhanced skills, knowledge and deployment of nursing staff with the
31
32
33 right levels of expertise to better address the acute illnesses of children of all ages but also to more
34
35
36 adequately treat and support children living with long term health conditions. Such conditions may
37
38 include a complex mixture of physical, behavioural, psychological and social problems that are being
39
40
41 sustained and perpetuated over time. PACK Child is ideally placed to meet these needs if structural
42
43 changes facilitate a clinical practice that orientates to continuous rather than episodic care. Previous
44
45
46 evidence has already emphasised the need for a more systematic implementation programme of
47
48
49
IMCI[44, 45], and for not relying solely on training to improve quality of care. Our evidence supports
50
51 this recommendation but emphasises that without reorienting primary health care towards a view
52
53
54 of the child and family evolving over time, the full range of health and social needs of children will
55
56 remain unaddressed[13].
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 At a meso level, the capacity for clinicians working in a busy facility environment to deliver care that

1 adequately addresses a complex array of needs, whilst also meeting provincial requirements to
2
3
4 complete documentation is clearly challenging. In addition, while in theory comprehensive services
5
6 are available for selected conditions at facilities, caregivers and children often have to see multiple
7
8
9 clinicians in order to receive the care they require. Additional touchpoints are likely to entail
10
11
12 increased loss to follow-up, are not person-centric, may be an inefficient use of clinical resources as
13
14 well as presenting infection control risks for children. The PACK Child guide is designed to support
15
16
17 clinicians to provide more comprehensive care without unnecessary duplication. The inclusion of all
18
19 cadres of staff in training and the addition of a “health systems strengthening” session examining
20
21
22 the distribution of roles among these cadres at different points in the facility visit represent initial
23
24
25
attempts to streamline care. Additional recommendations are provided in our overview paper.
26
27
28
29
30 The need to carefully consider how to deploy resources to effectively meet the range of children’s
31
32 needs is particularly pertinent for screening and responding to psychosocial issues surrounding the
33
34
35 child. Our findings demonstrated that asking caregivers about psychosocial issues may have limited
36
37
38
impact when embedded as part of a list of routine screening questions. Similarly, clinicians need to
39
40 know how to respond appropriately when psychoscocial issues are disclosed. As well as clearly
41
42
43 mapping social and community resources before introducing PACK Child at a facility, alternative
44
45 solutions to routine screening within consultations could lie in mobilising community health workers
46
47
48 to build relationships with families and ask more specific and targeted questions that might support
49
50 the child more effectively over the long term [46].
51
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 At a micro level, detailed consideration is required regarding how to better integrate medical record

1 stationery alongside PACK Child, so as to streamline and free up consultation time, which will allow
2
3
4 for more involvement of caregivers and children. Consultations have to be optimised to maximally
5
6 benefit the child, not just in terms of their specific problem on the day but an approach that enables
7
8
9 the child’s history and onward referrals to be tracked and followed on through at subsequent
10
11
12 consultations and with different professionals. In this respect the ICS offers advances over the IMCI
13
14 Checklist and has been adopted for Province-wide implementation since completion of this study.
15
16
17 Caregivers provided detailed accounts of their children’s healthcare utilisation and symptoms in this
18
19 study, and should not be overlooked in systems that cannot guarantee continuity of provider.
20
21
22
23
24
25
Strengths and Limitations
26
27 This process evaluation was to our knowledge the first study in LMICs to use a linguistic
28
29
30 ethnographic methodology to map salient macro-, meso- and micro-contextual features of child
31
32 health systems and attempt to identify relationships between different contextual features and the
33
34
35 implementation of a complex healthcare intervention within clinical consultations. By analysing
36
37
38
clinician-caregiver-documentation interactions and working laterally across different data types, we
39
40 were able to generate theoretical generalisations regarding the relationship between the broader
41
42
43 context of South African healthcare and the specific moments of delivery in which PACK Child was
44
45 being introduced. A particular strength of this analysis was the extensive use of observational data
46
47
48 and identification of misalignments to delivery, functioning as telling cases that expose broader
49
50 tensions between the existing healthcare system and the PACK Child intervention. This presented a
51
52
53 significant advantage over solely relying on stakeholder perspectives of delivery in order to
54
55
56 understand the realities of embedding a new complex healthcare intervention into existing practice.
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 Our observations of consultations were likely affected by the researcher’s presence and limited by

1 the timing of data collection, which was both during and immediately following completion of the
2
3
4 PACK Child training programme. This meant that we were observing clinicians who had limited time
5
6 to develop their skills using all components of the PACK Child guide and may have been anxious
7
8
9 about the researcher judging their performance. However, our focus was not solely on the extent
10
11
12 to which clinicians followed each element of the guide, but more specifically how their use of the
13
14 guide and interaction with caregivers and children was a result of the contextual conditions under
15
16
17 which they were working. As we have described this included a negotiation of PACK Child alongside
18
19 other documentation.
20
21
22
23
24
25
We faced some difficulties recruiting and selecting a diverse group of children and caregivers as we
26
27 were reliant on which children presented on any given day and on the availability of nurses to enable
28
29
30 us to observe consultations. Only ten of the 53 consultations were for children presenting with
31
32 chronic conditions and only two of these were scheduled visits. Two PHC facilities held dedicated
33
34
35 asthma and eczema clinics and it is possible that other scheduled visits produced different
36
37
38
behaviours to the ones we observed.
39
40
41
42
43 This research was carried out in the Western Cape province, inevitably limiting the transferability of
44
45 the findings to parts of South Africa with fewer doctors and clinical nurse practitioners. However, a
46
47
48 key objective of this study was to identify how best to optimise the delivery of PACK Child,
49
50 generating recommendations for both the design of the intervention and the organisation of
51
52
53 paediatric care more generally. For example, while Integrated Clinical Stationery is a Western Cape
54
55
56 initiative, our findings emphasise the need for caution about the form and quantity of
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 documentation generally, which may function to perpetuate risk minimisation and reduce person

1 centredness, applicable no matter what stationery is used. The depth of the analysis within this
2
3
4 study unpicked relationships between intervention and context that are far-reaching beyond the
5
6 specific documentation, skills and resources that we observed in the Western Cape, offering wider
7
8
9 theoretical generalisability, both in South Africa and low and middle income countries generally.
10
11
12
13 CONCLUSIONS
14
15
16 More than two decades since IMCI was introduced, our findings reveal that a review of the
17
18 priorities for paediatric healthcare are now required, alongside a detailed consideration of how
19
20
21 different policies are translated into practice at an institutional level. Health systems need to buy
22
23
24 into a transitional space where both risk minimisation and longer term care for the child over time
25
26 can be more readily accommodated through review of who provides what care in what
27
28
29 consultation. This includes making a shift from risk minimisation on the day to risk minimisation
30
31 and promotion of wellness over time. Once such an approach is in place facilities will arguably be
32
33
34 better placed to tackle a range of problems including complex psychosocial issues that may
35
36
37
surround the child. The PACK Child guide and training programme could be instrumental in
38
39 initiating such a shift on the ground within the realities of everyday primary care. To maximise its
40
41
42 potential requires a healthcare system that makes a similar shift from acute illness paradigm to a
43
44 larger remit of enabling the child to survive, thrive and transform.
45
46
47
48
49
List of Abbreviations: Human Immuno-deficiency Virus (HIV); Integrated Clinical Stationery (ICS) ;
50
51
52 Integrated Management of Childhood Illness (IMCI); Knowledge Translation Unit (KTU); Lower-
53
54
55 middle-income country (LMIC); Practical Approach to Care Kit (PACK); Primary Health Care (PHC);
56
57 Road to Health Booklet (RtHB); Tuberculosis (TB); World Health Organisation (WHO)
58
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 DECLARATIONS

1 Ethics approval and consent to participate: Approval was obtained from University of Cape Town
2
3
4 Human Research Ethics Committee (568/2017), City of Cape Town Research Ethics Committee
5
6 (7876) and the Western Cape Provincial Health Research Committee (WC_201709_011). Research
7
8
9 participants provided informed consent before any data collection commenced. Where participants
10
11
12 were children (under 16 years old), written informed consent was obtained from caregivers (parents
13
14 or guardians). Children over seven years old were also asked to give assent to their participation.
15
16
17 Consent for publication: All participants have consented for the findings of the study to be
18
19 published with their identity anonymised.
20
21
22 Availability of data and materials: The datasets generated and/or analysed during the current
23
24
25
study are not publicly available due to data transcripts including personal participant information
26
27 not suitable for sharing, but are available from the corresponding author on reasonable request.
28
29
30 Competing interests: We have read and understood BMJ policy on declaration of interests and
31
32 declare that Lara Fairall, Eric Bateman, Robyn Curran, Makhosazana Lungile, and Sandra Picken are
33
34
35 employees of the KTU. Professor Bateman reports personal fees from Novartis, Menarini, ALK,
36
37
38
Sanofi Regeneron, Boehringer Ingelheim and AstraZeneca, for work outside the submitted work.
39
40 Professor Bateman is also a Member of Global Initiative for Asthma Board and Science Committee.
41
42
43 Since August 2015 the KTU and BMJ have been engaged in a non-profit partnership to provide
44
45 continuous evidence updates for PACK, expand PACK related supported services to countries and
46
47
48 organisations as requested, and where appropriate license PACK content. The KTU and BMJ co-fund
49
50 core positions, including a PACK Global Development Director, and receive no profits from the
51
52
53 partnership. PACK receives no funding from the pharmaceutical industry.
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 Funding: This research is funded by the Joint Health Systems Research Initiative (Department for

1 International Development, Economic and Social Research Council, UK Medical Research Council
2
3
4 and Wellcome Trust). Grant ref: MR/R004080/1. The funder had no role in the design of the study,
5
6 collection, analysis, interpretation of data or writing of the manuscript.
7
8
9 Authors’ contributions: All authors contributed to the conceptualisation of the research and
10
11
12 contributed to writing the manuscript. LF, EB, RVC, MB, JM and RC designed the process evaluation
13
14 protocol. MLS and SCP led the development of the PACK Child training intervention. RVC led the
15
16
17 development of the content of the PACK Child guide. JM and RC collected, analysed and
18
19 interpretation of all data. JM drafted the manuscript and all co-authors edited and commented on
20
21
22 revised drafts. All authors approved the final draft for submission. All authors agree to be
23
24
25
accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity
26
27 of any part of the work are appropriately investigated and resolved.
28
29
30 Acknowledgements: We would like to thank all caregivers and children, clinicians, managers,
31
32 policymakers and trainers who participated in the process evaluation. The University of Cape Town
33
34
35 Lung Institute and The Children’s Hospital Trust, South Africa provided funding to support the
36
37
38
development of the PACK Child guide. Lara Fairall acknowledges funding from the UK's National
39
40 Institute of Health Research (NIHR) through King’s College London’s ASSET Programme on Health
41
42
43 Systems Strengthening in sub-Saharan Africa (16/136/54).
44
45
46
47
48 REFERENCES
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50 1. WHO. Every Woman Every Child. Global strategy for women’s, children’s and adolescents’ health
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25 lessons learnt from IMCI and iCCM. BMJ. 2018; 362: p. bmj.k3013.
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6 29. Chopra, M et al. Effect of an IMCI intervention on quality of care across four districts in Cape Town,
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12 32. Rampton BK, Maybin TK, Barwell J, Creese RA and Lytra V. UK linguistic ethnography: a discussion
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35. Naidoo H, Avenant T and Goga A. Completeness of the Road-to-Health Booklet and Road-to-Health
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20 36. Qaseem A et al. Guidelines International Network: toward international standards for clinical
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22 37. Schünemann HJ et al. Guidelines 2.0: systematic development of a comprehensive checklist for a
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successful guideline enterprise. Canadian Medical Association Journal. 2014; 186(3).
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25 38. Mitchell JC. Typicality and the case study. Ethnographic research: A guide to general conduct, 1984.
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27 39. Stivers T. Parent resistance to physicians' treatment recommendations: one resource for initiating a
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29 40. Jefferson G. Glossary of transcript symbols with an introduction. Pragmatics and Beyond New
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33 South Africa. 2014.
34 42. Stivers T and Enfield N. A coding scheme for question-response sequences in conversation. Journal
35 of Pragmatics. 2010; 42.
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43. Heritage J. Questioning in medicine. In: Freed S, Editor. Why do you ask?: The function of questions
38 in institutional discourse. New York: Oxford University Press; 2009. p. 42-68.
39 44. Pandya H, Slemming W, and Saloojee H. Health system factors affecting implementation of
40 integrated management of childhood illness (IMCI): qualitative insights from a South African
41 province. Health Policy and Planning. 2018; 33(2).
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45. Health Systems Trust. South African Health Review. 2016.
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44 46. Kagee A et al. Screening for common mental disorders in low resource settings: reasons for caution
45 and a way forward. International Health. 2012; 5(1).
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 1
2
3
4
5
6
7
8
9
10
Table 1. Macro-contextual features of paediatric primary care
11
12
13 Type of macro discourse, Description
14 policy in play
15
16 Integrated Management of World Health Organisation’s IMCI is an integrated strategy that is targeted at
17 Childhood Illness (IMCI) reducing death, illness and disability, and promoting growth and development for
18 children 0-5 years old, this strategy comprises both preventive and curative
19 elements and has three components targeted at improving skills of primary care
20 clinicians, health systems functioning, and family and community health practices.
21 Principally delivered by nurses, IMCI is underpinned by a risk minimisation approach
22 with the main aim of a provider-patient contact to ensure all children with danger
23 signs are referred to the next level of care and provide reassurance that growth
24 monitoring (and associated interventions e.g. Vitamin A) and immunisation take
25
place.
26
27
28 IMCI was introduced in South Africa in 1996 with a primary implementation focus
29 on training and capacity building of clinicians. (1) In the Western Cape, the main
30 manifestations of IMCI are the chart booklet, last updated in 2014, a training
31 programme that targets professional nurses with the intention that they then see
32 children, and the IMCI checklist.
33
34 Primary Health Care Standard National level guidance comprising evidence based standardised recommendations
35 Treatment Guidelines (STG) and for healthcare workers, in order to promote equitable access to safe, effective, and
36 Essential Drug List (EDL) affordable health medications. These guidelines are not specific to children and
37 include adults. There is limited guidance for neonates. Medication for children is
38 recommended according to weight bands.[41]
39
40 Expanded Programme on Vaccination schedule updated in December 2015, implemented in provincial and
41 Immunization (EPI SA) municipal clinics, reducing in frequency after children reach 18 months old. HPV
42 vaccine targets girls aged nine years.
43
44
First 1000 Days Initiative The first 1000 days initiative aims to improve the nutrition of mothers and children
45
46 during the first 1000-day window to ensure children get the best start to life and
47 the opportunity to reach their full potential, starting from conception, moving
48 through pregnancy, birth, and after the first 2 years of life.
49
50 Nurturing Care Framework The Nurturing Care Framework provides a roadmap for how early childhood
51 development unfolds and how it can be improved by policies and interventions. It
52 outlines: why efforts to improve health, well-being and human capital must begin
53 in the earliest years, from pregnancy to age 3; the major threats to early childhood
54 development; how nurturing care protects young children from the worst effects of
55 adversity and promotes development – physical, emotional, social and cognitive;
56 and what caregivers need in order to provide nurturing care for young children.
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 Nurse restrictions on IMCI-trained nurses treating children are typically professional nurses with
prescribing prescribing limited to treating acute symptoms only. Restrictions are in place for
1 medications used to manage long-term conditions including inhaled corticosteroids
2 for asthma and topical steroids for eczema. This results in referrals, with additional
3 waiting time and contact, to clinical nurse practitioners or doctors for prescriptions
4 to treat chronic conditions.
5
6
They need to treat their client according to their scope of practice. They can only
7
prescribe according to a schedule, in fact according to the national EDL [Essential
8
9 Drugs List], where it says for this condition you can only give a certain treatment.
10 (Manager interview, Phase 1)
11
12 Chronic Illness Management Nurses lack experience with chronic illness management at primary care level.
13 and training for over 5s
14 “I: How often do you come back for the asthma medication?
15 CG: They didn't put her on medication. They just said that I must see...look after. I
16 must just keep an eye that her chest doesn't tighten. I must bring her back
17 immediately once this happens, or take her to the hospital, but they gave her an
18 inhaler.” (Caregiver, Phase 2)
19
20 No specific guidelines or stationery for children above 5, until introduction of
21 Integrated Clinical Stationery (Western Cape only – see below)
22
23
“Our clinical notes for the child older than 5 years we only use our clinical notes to
24
make an entry we don't have a form like this for children older than 5 years.”
25
26 (Manager, Phase 2)
27
Road to Health Booklet (RtHB) RtHB provided as patient medical record, widely implemented in PHCs throughout
28
29 South Africa. Underpinned by philosophy to support well child routine visits,
30 continuity of information and provide a hand held record for caregivers that
31 summarises the child’s health in the first five years of life. The RtHB was
32 substantially revised and expanded to include health promotion messages in
33 February 2018 (https://www.westerncape.gov.za/general-publication/new-road-
34 health-booklet-side-side-road-health).
35
36 Integrated Clinical Stationery ICS was developed by the Western Cape Department of Health in 2015 following
37 (ICS) identification of a gap in clinical recordkeeping for children during a pilot audit in
38 facilities. Facility records for routine care were found to be inadequate and IMCI
39 checklists were scattered in patient’s folders in no particular order. ICS was
40 designed to meet the need for facility and visit-based stationery that integrated
41 well and sick child care. The stationery was piloted in five facilities from July 2016
42 and implemented in half of PACK Child pilot facilities at the time of this study. It
43 has since been adopted for Province-wide implementation.
44
45 Patient co-payments In South Africa primary care is free at point-of-care including access to a wide
46 range of medications and investigations for people of all ages. Hospital-level care
47
is free for all pregnant women and children under 5.
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 Table 2. Meso-contextual features of paediatric primary care

1 Institutional relations, workforce Description

2 arrangements, local policy
3
4 Services typically provided by Municipal PHC facilities typically provide well child services (i.e. growth
5 municipal and provincial facilities. monitoring, development screening and immunisations on appointment
6 basis), and services for sick children aged 0-5 years. Provincial government
7 facilities provide services to all sick and well children, with a high proportion
8 of children aged 0-5 years.
9
10 Delineated clinical roles and multi- Professional nurses trained in IMCI routinely see sick children under the
11 disciplinary working age of five. In rural facilities, CNPs are typically the first clinician to consult
12 a child. Doctors do not routinely see children other than those who are
13 severely ill or attending follow-up clinics for TB or HIV care. Enrolled Nurses
14 typically run immunisation services and perform growth monitoring.
15
16
I: Do any doctors see children?
17
18 M: Yes
19 I: And is it only when they need they need extra assistance for
20 cases, or do they see them regularly?
21 M: Yeah, she prefers to see all those that are on ART and if it's an
22 emergency. (Manager Interview, Phase 3)
23
24 Facilities frequently rotate their staff.
25
26 M: Most are IMCI trained, on a regular basis I rotate but certain
27 such as ARV and TB we cannot rotate as it is specialist. So that if
28
29 someone is sick, others can float because of this. This ensures that
30 the service is accessible, they all have the exposure.” (Manager
31 interview, Phase 1)
32
33
34 Caregiver seeking behaviour Children with HIV, TB and other chronic conditions referred to larger PHC
35 facilities (“community health centres”)
36
37 M: No, we don't see many chronic we refer them to ((name))
38 Community Health Centre..
39 I: So they don't come here for repeat scripts or...
40 M: No. So when they... it’s whereby maybe there will be diagnosed
41 for the first time here, for instance if the client is coming, let's say
42 for eczema, that child will be treated for eczema. If the child
43 maybe got severe eczema, then he will get transferred to ((name
44 of tertiary level hospital)) then ((name of tertiary level hospital))
45
will bring it back that this child needs to be treated like a chronic
46
child. There that time will refer back because they’ve got all the
47
48 resources at ((name of hospital)) unlike us. (Manager interview,
49 Phase 2)
50
51 Flow of children through facilities Registration: For children requiring immunisations, care was typically
52 accessed through an appointment system. Caregivers with a scheduled visit
53 for an immunisation or growth monitoring arrived with their RtHB and
54 placed it at a specific registration point with a box for appointments.
55 Caregivers with children without appointments, coming for an acute
56 condition or having missed scheduled visits, placed their RtHB in the non-
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 appointment box at the registration desk. Patient records were
subsequently retrieved by reception staff and placed in the weighing and
1 triage area according to the order in which they arrived.
2 Weighing/ and triage area: The weighing and triage area was either a room
3 or open area where children were weighed and reason for the visit
4 established. In the majority of facilities an enrolled nurse, with more
5 limited clinical training than professional nurses, was allocated to the
6
weighing area. Weights were measured but typically not plotted or used to
7
interpret growth. Heights were not routinely measured in most facilities.
8
9 Temperatures were taken if the child was feverish. Both sick and well
10 children came through the weighing/triage area. Guided by the child’s
11 RtHB, the nurse determined if the child required vitamin A and deworming
12 medicine. Children were separated into emergencies, well, or sick child
13 visits and allocated to the relevant nurse, typically based on the caregiver’s
14 report of the presenting complaint, rather than through the nurse’s clinical
15 assessment. In two facilities, this area also functioned as the immunisation
16 room. In one facility, children were weighed and given immunisations in
17 the consultation room. The triage area typically had a dehydration corner
18 and breastfeeding area.
19 Well child: Typically seen in the immunisation room. Caregivers and
20
children waited in the waiting area to be called by the allocated nurse. The
21
immunisations were mainly carried out by an enrolled nurse but in some
22
23 cases, a professional nurse. Following the immunisation, the nurse plotted
24 the child’s weight in the RtHB. Caregiver/child would then leave with their
25 updated RtHB.
26 Sick child: Between one and three nurses in each facility were allocated to
27 see sick children. These nurses were generally professional nurses, who
28 then reported to a clinical nurse practitioner or doctor. In two facilities, sick
29 children were prioritised and seen before adults. If the child was classified
30 as an emergency, they went straight to the trauma room. Most of the
31 consultation rooms for sick children had a stock of medication to dispense
32 but, in some cases, caregivers had to go to the pharmacy to collect their
33 prescription. In one facility, caregivers/children were required to see
34
approximately four people if also needing treatment for Prevention of
35
36 Mother to Child Transmission (PMCT) of HIV, including nurses to: triage,
37 give immunisations, treat acute conditions and deliver PMTCT.
38
Local protocols/documentation for - Immunisation, developmental screening, deworming, vitamin A
39
40 treating children supplementation, health promotion and growth monitoring: RtHB and
41 IMCI checklist or Integrated Clinical Stationery (ICS)
42 - Sick child (0-5 years): IMCI checklist or ICS
43 - Sick child (6 years and above): ICS.
44 - Referral forms
45 Provincial departments of health require facilities to complete stationery
46 with IMCI components for consultations with children 0-5 years. ICS
47 stationery also includes information about family, social context and
48 chronic conditions (other than HIV and TB). ICS pages designed in columns
49 to track previous visits.
50
51
Province applies IMCI audit tools to determine clinician alignment with
52
IMCI guide and whether facilities are treating expected numbers of
53
54 children. IMCI audit data fed back to national Department of Health and
55 WHO figures on child mortality.
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 Pattern of care-seeking from PHC The primary health care service offering is chiefly structured as preventive
services care (immunization and growth monitoring) and curative (acute illness),
1 both in children under 5, which over time has shaped care-seeking patterns
2 at community level. Children with chronic illnesses such as asthma rarely
3 receive routine care in primary care, and are often referred to secondary
4 and tertiary services which are usually some distance from communities, or
5 the Community Health Care Centres where there is little continuity of care
6
outside HIV and TB treatment programmes. This perpetuates poor care
7
seeking outside acute episodic illnesses and does not grow an
8
9 understanding of regular, planned care for children with long-term health
10 conditions. Caregivers frequently make use of an extensive network of
11 private General Practitioners who provide acute episodic care and
12 medication for a fixed fee, but rarely chronic care.
13 I: Do you think many children come with a chronic illness problem,
14 or do they come with an acute symptom?
15 M: The majority is acute symptoms, but here and there we have
16 babies that is on asthmatic treatment also, but the majority is
17 acute, and the majority is pneumonia cases, severe pneumonia
18 cases. (Manager Interview, Phase 3)
19
20 Referrals and continuity of information Facilities reported rarely receiving feedback from hospitals following
21 patient referrals. Caregivers received discharge summaries from referral
22 centres but did not routinely bring them to PHC facilities.
23
24
25
26
27 Additional Files
28
29 1. File Name: Additional File 1
30
31 File format: Additional file 1.pdf
32 Title of Data: Child > 2 months old: Routine Care
33
34
Description of Data: Sample of routine care page from PACK Child guide
35
36 2. File Name: Additional File 2
37
38 File format: Additional file 2.pdf
39 Title of Data: Sick Child Age 2 months to 5 years
40 Description of Data: Sample of IMCI Checklist
41
42
43 3. File Name: Additional File 3
44
45
File format: Additional file 3.pdf
46 Title of Data: Integrated Stationery for children < 5 years
47 Description of Data: Sample of Integrated Clinical Stationery used for children less than 5
48
49
50 4. File Name: Additional File 4
51 File format: Additional file 4.pdf
52
53 Title of Data: Road to Health Booklet
54 Description of Data: A sample of the road to health booklet (version used during the pilot)
55
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57 5. File Name: Additional File 5
58
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 File format: Additional file 5.pdf
Title of Data: Observation guide-Non Clinical Areas
1 Description of Data: Observation guide for non-clinical areas
2
3
4 6. File Name: Additional File 6
5
6
File format: Additional file 6.pdf
7 Title of Data: PACK Child Training Programme and Cascade Model
8 Description of Data: Model of Training and Cascade Model
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Child > 2 months old: Routine Care Click here to access/download;Figure;Additional File 1.pdf

Child ≥ 2 months old: routine care

Record problems and plot growth in notes and Road to Health Booklet (RtHB).
Assess When to assess Note
Symptoms If sick visit Manage symptoms on symptom page contents. If child is seriously unwell, manage symptom first.
Feeding Every visit if Determine method of feeding. Ask carer if feeding problem. If yes, assess and manage further: if breastfeeding (or mixed feeding) 87, if formula feeding 89, if eating solids 90.
< 2 years old
Growth Check chart 14 Interpret measurements 15. If born premature, use corrected age1 until 2 years.
Development Every visit Ask “Is child able to say and do what children of the same age can?” If no, manage problem: if vision problem 44, if communication problem 81, if not moving or sitting
(Screen at every properly 82.
visit. Also check 14 weeks old If unable to follow a close object with eyes 44. If does not respond (stops sucking, blinks or turns) to sound 81. If unable to lift head when held against shoulder 82.
routine milestones
at specific ages 6 months old If unable to recognise familiar faces 44. If does not turn to look for sound 81. If unable to hold a toy in each hand 82.
listed.) 9 months old If unable to focus on a far object or has a squint 44. If does not turn when called 81. If unable to sit and play without support 82.
15 months old If unable to stand on his/her own 82.
18 months old If not looking at or reaching for small objects or pictures 44. If unable to point to 3 simple objects, uses < 3 words, does not obey simple commands 81. If unable to walk
unsupported or if unable to feed using fingers 82.
3 years old If unable to see small shapes clearly from 6 metres 44. If unable to talk in simple 3-word sentences 81. If unable to run or climb 82.
5 years old If any problem with vision 44. If unable to speak in full sentences or not interacting with children and adults 81. If unable to hop on one foot or draw a stick person 82.
Well child visits Every visit Check if immunisations, deworming, vitamin A are up to date in RtHB and what is due at this visit 14. If missed doses, catch up 13.
HIV Every visit if • If HIV status unknown, decide if HIV test is needed 105.
not known • If HIV negative and breastfeeding, check that mother tests for HIV every 3 months.
HIV positive • If HIV-exposed (mother HIV positive), check child has had routine HIV tests 105. Ensure the HIV-exposed baby is receiving PMTCT 111.
• If HIV positive, ensure on ART and give routine HIV care 106.
TB Every visit If close TB contact 98. If TB symptoms (cough or fever ≥ 2 weeks, not growing well/losing weight, tired/less playful) 100.
Mother/carer Every visit Ask about general health, HIV status, contraceptive needs and TB symptoms PACK Adult.
Psychosocial risk Every visit • If child support grant needed, advise to take child’s birth certificate and carer’s ID to SASSA2 to apply.
• Look for increased psychosocial risk (carer/parent < 20 years old, family/relationship problems, violence at home, lack of partner/family support, financial difficulty, difficult life
event in last year, foreigner): give additional support, review more often if needed and if relevant, link with support services/helpline 134.
• Screen for depression in carer: in the past month, has carer: 1) felt down, depressed, hopeless or 2) felt little interest or pleasure in doing things? If yes to either PACK Adult.
• If yes to both of the following 85: 1) Are you struggling with or feeling overwhelmed by parenting? 2) Would you like help with this?
• If abuse or neglect suspected 78.
Mental health Every visit If over past few months, child has been miserable, stressed or angry 79 or if problematic change in behaviour 80.
School problems If ≥ 6 years old: • Check if child at school: if not enrolled in school, refer to social worker.
every visit • If poor attendance, bullying, learning problems, difficulty socialising at school 83.
Basic examination Every visit Check for obvious problems (if < 2 years old, undress child fully): pallor3 42, skin problem (especially nappy area) 67, injury 32, if deformity, discuss/refer.

Continue to advise and provide routine care treatment  13.

1
Corrected age = actual age in months (or weeks) - number of months (or weeks) premature. To calculate corrected age of 9 month old baby, born premature at 32 weeks (this is 8 weeks or 2 months premature): 9 months - 2 months = 7 months. 2South
Africa Social Security Agency. 3Look for palmar pallor: child’s palm is much less pink than your own. Also look for conjunctival pallor: look for paleness of the lower inner eyelid.
12
Sick Child Age 2 months to 5 years Click here to access/download;Figure;Additional File 2.pdf
Integrated Stationery for children < 5 years INTEGRATED STATIONERY FOR CHILDREN
Click≤5 YEARS
here v.201902
to access/download;Figure;Additional File 3.pdf
PATIENT DETAILS ALLERGIES / ADVERSE DRUG REACTIONS

Date
First name
Surname
DOB / / Sex M / F
ID Number

Enter results of annual/frequent tests, drug changes, hospitalisations or observations for monitoring. Insert own headings if needed.
Address: Emergency contact name:
Caregiver(s) name: Tel.: Tel.:
(circle one and write name below in Facility name
Tel.: Tel.: ECD centre | School | Care field)
Other contact name: Tel.: Facility name: Tel.:

Family / social context Birth information

Caregiver(s): Mother | Mother&Father | Other details Weight kg Length cm HC cm Apgar

Caregiver(s) name(s): Delivery mode NVD | C/S | BBA

Caregiver(s) address: Delivery facility

Mother HIV+
Caregiver(s) health status Healthy | Unwell Y | N | Ukn Birth PCR Y | N | N/A result
in labour
Caregiver(s) risks Teen Mom | Substances | Other details ART prophylaxis NVP | AZT TB exposed Y | N
Caregiver
Salary | Casual | Grant | Other details Neonatal feeding EBF | EFF | Mixed
income
No. children in HH/ premises: ≤ 5yrs number | >5 to 18 yrs number At risk neonate Twin | LBW | Prem | Hospital Admission |

Notes
Housing Formal | Informal details Electricity Y|N | Other details

Water supply Piped inside | Piped outside | Not piped Notes

Sanitation Flush toilet | Bucket | Communal

Developmental
Immunisations HTS Vit A Deworm Oral Health
screen
Age Date Date Date
Date Vaccine Site* Batch no. Date performed Date performed
group performed performed performed
BCG R arm
Birth
OPV0 Oral
OPV1 Oral
RV1 Oral
6w
PCV1 R thigh
Hexaxim1 L thigh
10 w Hexaxim2 L thigh
RV2 Oral

14 w PCV2 R thigh
Hexaxim3 L thigh

18 w high risk
6m Measles 1 L thigh

9m PCV3 R thigh

12 m Measles 2 R arm
18 m Hexaxim4 L arm

2 yrs
2 yrs 6m

3 yrs
3 yrs 6 m

4 yrs
4 yrs 6m

5 yrs
6 wks post
cess. BF

* If child R Handed then L arm. If child L Handed then R arm.

Enter details on longterm health conditions, medical, surgical and social history overpage
 Y N
LONG TERM HEALTH CONDITIONS AND NOTES Date: dd / mm / yyyy Time of initial assessment: Emergency Triage Colour

(for date diagnosed of other conditions, detailed social history and life course information) Age: (wk / months / years) Who brought child in: Principal caregiver: Mother | Other

Observations and Screening

Baseline completed Date of baseline completion: dd/mm/yyyy Ask reasons for visit details Well | Sick | Trauma If sick ≤2m use IMCI stationery
Action Y N N/A
Danger signs: <2m old | consult in past 2days | lethargic or unconscious | fever
taken
Diagnosis vomiting | convulsions | not feeding | cough | difficulty breathing | diarrhoea | weakness details

Y N
Action
Developmental dd/mm/yyyy details HIV Diagnosis dd/mm/yyy baseline CD4 Temp: RR: HR: Sats: Pallor HB: Y N N/A
taken
Disability dd/mm/yyyy details Baseline staging 1 2 3 4 Wt (kg)
Ht/ Length
MUAC (cm) HC (cm) details
(cm)
Congenital dd/mm/yyyy details ART Prior ART dd/mm/yyy drug(s) Feeding: Age <6m | ≥6m EBF | EFF | BF | FF | Solids Problem Y N details

Epilepsy dd/mm/yyyy details Start dd/mm/yyy drug(s) Growth: Norm | OW | Faltering | MAM | SAM | Catch up | Stunted Devel: Norm | Problem details
Oral
Asthma dd/mm/yyyy details TFI dd/mm/yyy Transferred from Immun: UTD | Due Deworm: UTD | Due Vit A: UTD | Due
health:
Norm | Problem details
Restart/ TB Rx
Rhinitis dd/mm/yyyy details dd/mm/yyyy drug(s) On TB Rx Y N (months) TB Screen: Cough | TB Contact | Fever | Not growing well | Fatigue or playing less
change duration
Next HIV Y N N/A
Eczema dd/mm/yyyy details IPT Start dd/mm/yyy HIV status: Known pos | Neg last test | Unkn
test due:
Today | Other dd/mm/yyyy On IPT
Duration on current Next VL Y N N/A
Allergic dd/mm/yyyy details TB Rx 1st Treatment dd/mm/yyy ART:
(months)
test due:
date On Bactrim Duration on IPT months
Conjuctivitis Condoms Y N N/A
TB Outcome DSTB DRTB Mother: Well Y N N/A HIV: Known pos | Neg last test | Test due FP: UTD | Due type

Care-
giver
used
Other dd/mm/yyyy details Cured | Complete | Default | Failure Caregiver: Mother | Other TB Y N Substance abuse Y N Psychosocial risk Y N details

Other dd/mm/yyyy details 2nd Treatment dd/mm/yyy Time of consultation: Routine care: Immunise | Vit A | Deworm

Other dd/mm/yyyy details TB Outcome DSTB DRTB

Cured | Complete | Default | Failure

History and Exam

Additional notes on medical/surgical/social history:

Other IMCI: Measles | Ear problems | Sore throat | Other

Assessment / Diagnosis / Problem List Management / Medication / Supplements

Assessment and
Management
2

4
ART med(s) Y N
Referral Y N details ART prescribed Duration Prescribed
change:

Counselling/ Health Education: details / record on counselling stationery Updated RTHB Y N

Name: Signature:
Counselling given Y N Consent Y N
for HIV test | Other procedure type given:
Parent | Caregiver

POS | NEG POS | NEG Write test details POS | NEG POS | NEG
CHILD: HIV Test screening confirmatory overpage MOM: Rapid HIV Test screening confirmatory

Data Elements VL result TST POS | NEG X-rays Norm | Abn (enter details on back of outer)

Urine dipstix result Urine MC & S result

Other test: type result Other test: type result Other test: type result

BCG RV1 OPV1 HX1 PCV1 HX2 RV2 PCV2 HX3 M1 PCV3 HX4 M2

FImm Vit A DeW EBF EBF14 MAM SAM FdSup TD1 TD2 HPV1 HPV2
Other

DD DND Pneu ASTHv HIVv TBv TBs TBsHIV TBcASx TBSx IPTeHIV TBcIPTi IPTiHIV

Appt Ref Disch. OHv EPILv MHv

Allied health Allied health Allied health Allied health Other Other Other

PN DR OHP Allied HP Allied profession Other: Job type/title Reason(s) for

next visit:
v.201905

Name:

Date of next visit:

SANC/HPCSA no. Date captured:
Clerk (sign):
Signature:
 Notes to guide completion of child stationery v.201905

For visit summary

1. For ‘emergency’ patients, complete the top line (Y or N and triage colour). Write ‘refer to Triage notes’ in the History and Examination section and use separate triage
stationery.
2. If extra space is required to record a visit, clearly mark PTO in the History/Examination block; on the space allocated at the back of the page, clearly mark the date of
these extra notes.
3. Where there are several choices, circle all that apply e.g. for feeding, one might circle 'FF' and 'Solids'.
4. Stippled blocks indicate IMCI classifications e.g. danger signs and feeding assessment in the top section of visit summary, and ‘Other IMCI’ at the bottom of History and
examination section.
5. Growth measurements are recorded in the visit summary, then plotted in the RTHB, and then interpreted in the visit summary. Growth: plot height & weight on growth chart in RTHB & interpret according to definition below. Note, circle multiple categories if needed eg MAM&catch
6. Development must be assessed as Normal/problem using the assessment questions in the RTHB. up
7. For Assessment and management section:
a. record an assessment/diagnosis and the management thereof on the same numbered line. For a chronic/ongoing condition, it is advisable to keep that
1. Normal growth: weight & height are appropriate for age & follow the normal growth curve (between the -2 to +2 lines). Note: with preterm & LBW
condition on the same line at every visit. infants, growth must follow their respective growth curve, which may be lower than in a full term infant.
b. Medications may be summarized in this section, as the full details will be on the prescription chart. 2. Overweight: assess weight for age and weight for height / length. If weight for age is above +3SD in the growth chart, plot it on the weight for height /
c. For ART, it is necessary (for data capturing purposes) to indicate the names of the ART prescribed at the visit, whether these have been changed at that visit, length chart. Classify as overweight (OW) if the weight for height / length is between +2SD and +3SD; classify as obese if weight for height / length
and the duration for which the ART has been prescribed. is > 3SD.
8. Details of counselling/health education could be entered in the separate counselling stationery. 3. Growth faltering: not gaining weight / flattening of growth curve on growth chart. If < 6 months: flattening over 2 consecutive visits. If aged 6 months
9. For HIV testing: consent for testing, and the results of the test are recorded in the visit summary. The details of the actual screening and confirmatory tests (names, batch – 5 years: flattening of curve over 2 months.
no., expiry date) are recorded on the section at the back of the visit summary.
10. Tests: tick the box associated with the test that is to be performed at that visit. When the result is received, record the result next to this ticked box i.e. in the record for
4. MAM: moderate acute malnutrition. Weight for height between -2 & -3 line or MUAC (children 6 months – 5 years) between 11.5 & 12.5 cm.
the visit at which the test was taken. 5. SAM: severe acute malnutrition: 1 of the following: Weight for height < -3 line; MUAC < 11.5 (children 6 - 60 months) or pitting oedema with normal
11. For sites where electronic capturing of RMR/other data is occurring: put a cross through the shaded block(s) which apply to that visit. For allied health professionals, weight.
enter t/he abbreviation of the relevant RMR element into one of the open boxes allocated for this and mark a cross over the element. In cases where a number is also 6. Catch up: growth improving after intervention for faltering growth or SAM / MAM.
required, include this. For example: Tex2 indicates 2 teeth extracted.
12. Putting a cross through a shaded date element for routine care indicates that the clinician has administered that treatment/prevention measure e.g. crossing through M1
indicates that the first measles immunistaion has been given. This action need not then be recorded again in the visit notes. Continuation notes (please date each entry and only use for visits included on the reverse)
13. If routine care is given, the table on the front of the outer must be updated.
14. The RTHB must be updated at every visit.
15. At the end of every visit, consider whether any updating of the patient summary (the ‘outer’) is required. Date

Data elements: RMR and other

BCG BCG Other:
HX 1 2 3 4 Hexaxim 1-4 HIVv Visit of a client with HIV
PCV 1 2 3 Pneumococcal vaccine 1-3 ASTHv Visit of a client with Asthma
RV 1 2 Rotavirus 1-2 EPILv Visit of a client with epilepsy
OPV 1 Oral Polio 1 MHv Mental health visit
M1 2 Measles 1-2 OHv Oral health visit
FIMM Fully immunised (under one year) Appt Client given appointment to return
TD1 2 Tetanus 1-2 Ref Client referred to another facility/service
HPV 1 2 HPV 1-2 Disch Client discharged with no appointment or referral
VitA Vitamin A
DeW Deworm
EBF Exclusively breastfed TB elements:
EBF14 Exclusively breastfed at 14 weeks TBs Screened for TB symptoms
MAM Moderate acute malnutrition (new) TBsHIV HIV positive client screened for TB
SAM Severe acute malnutrition (new) TBSx TB symptoms
FdSup Food supplements given (new) TBcASx TB contact but asymptomatic for TB
DD Diarrhoea with dehydration (new episode) TBcIPTi TB contact started on IPT
DND Diarrhoea with no dehydration TBv Visit of a client with TB
Pneu Pneumonia (new episode) IPTeHIV Newly diagnosed HIV positive child eligible for IPT
IPTi HIV Newly diagnosed HIV positive child initaited on IPT

Allied Health:
(use one/more block(s) to write relevant RMR elements)

WCr or Wci wheelchair required or issued

SPr or SPi spectacles required or issued
HAr or HAi hearing aid required or issued
Tex no. number of teeth extracted
Trest no. number of teeth restored
Tfs tooth fissure sealants 1st and 2nd permanent molar (child)

Abbreviations
ART Antiretroviral treatment MAM Moderately acute malnutrition (see definition)
AZT Zidovudine MC+S Microscopy culture and sensitivity
BBA Born before arrival MUAC Mid upper arm circumference
BF Breastfed (not exclusively) Norm. Normal
C/S Caesarian section NVD Normal vaginal delivery
Dev. Development NVP Neviripine
DOB Date of birth OHP Oral health practitioner
DSTB Drug sensitive tuberculosis OW Overweight
DRTB Drug resistant tuberculosis PCR Polymerase chain reaction test (HIV)
EBF Exclusively breastfeeding Prem. Premature infant (born before 37 weeks)
ECD Early childhood development Rif S/R Rifampicin sensitive or resistant
EFF Exclusive formula feeding RTHB Road to health booklet
FF Formula fed (not exclusively) RR Respitatory rate
FP Family planning (contraception) Rx Treatment (medication)
HB Haemaglobin SAM Severe acute malnutrition (see definition)
HC Head circumference Sats Oxygen saturation HIV Testing
HIV Human immunodeficiency virus TB Tuberculosis
HH Household Temp Temperature Test date: dd/mm/yyyy (enter results of tests in visit summary for this test date)
HR Heart rate TFI Transferred in
Ht Height TST Tuberculin skin test (Mantoux) Name of HIV screening test (PCR / Rapid) Batch no. Expiry Date
HTS HIV testing and support Unkn Unknown
IMCI Integrated management of childhood illnesses UTD Up to date
dd/mm/yyyy
Immun Immunisation Vit A Vitamin A
IPT Isoniazid preventive therapy VL Viral load (HIV)
LBW Low birth weight (<2.5kg) Wt Weight Name of HIV confirmatory test (PCR / Rapid) Batch no. Expiry date
dd/mm/yyyy
 Initial Assessment Date: dd / mm / yyyy Time of initial assessment: Emergency Y N Triage Colour Date: dd / mm / yyyy Time of initial assessment: Emergency Y N Triage Colour Date: dd / mm / yyyy Time of initial assessment: Emergency Y N Triage Colour

Age: (wk / months / years) Who brought child in: Principal caregiver: Mother | Other Age: (wk / months / years) Who brought child in: Principal caregiver: Mother | Other Age: (wk / months / years) Who brought child in: Principal caregiver: Mother | Other
Ask reasons Ask reasons Ask reasons
details Well | Sick | Trauma If sick ≤2m use IMCI stationery details Well | Sick | Trauma If sick ≤2m use IMCI stationery details Well | Sick | Trauma If sick ≤2m use IMCI stationery
for visit for visit for visit
Action Y N N/A
Action Y N N/A
Action Y N N/A
Danger signs: <2m old | consult in past 2days | lethargic or unconscious | fever Danger signs: <2m old | consult in past 2days | lethargic or unconscious | fever Danger signs: <2m old | consult in past 2days | lethargic or unconscious | fever
taken taken taken

vomiting | convulsions | not feeding | cough | difficulty breathing | diarrhoea | weakness details vomiting | convulsions | not feeding | cough | difficulty breathing | diarrhoea | weakness details vomiting | convulsions | not feeding | cough | difficulty breathing | diarrhoea | weakness details
Vitals & Measurem

Y N
Action Y N N/A Y N
Action Y N N/A Y N
Action Y N N/A
Temp: RR: HR: Sats: Pallor HB: Temp: RR: HR: Sats: Pallor HB: Temp: RR: HR: Sats: Pallor HB:
taken taken taken
Wt Ht/ Length MUAC HC Wt Ht/ Length MUAC HC Wt Ht/ Length MUAC HC
details (cm) details (cm) details
(kg) (cm) (cm) (cm) (kg) (cm) (cm) (kg) (cm) (cm)

Feeding: Age: <6m | ≥6m EBF | EFF | BF | FF | Solids Problem Y N details Feeding: Age: <6m | ≥6m EBF | EFF | BF | FF | Solids Problem Y N details Feeding: Age: <6m | ≥6m EBF | EFF | BF | FF | Solids Problem Y N details

Growth: Norm | OW | Faltering | MAM | SAM | Catch up | Stunted Devel: Norm | Problem details Growth: Norm | OW | Faltering | MAM | SAM | Catch up | Stunted Devel: Norm | Problem details Growth: Norm | OW | Faltering | MAM | SAM | Catch up | Stunted Devel: Norm | Problem details
Oral Oral Oral
Routine

Immun: UTD | Due Deworm: UTD | Due Vit A: UTD | Due Norm | Problem details Immun: UTD | Due Deworm: UTD | Due Vit A: UTD | Due Norm | Problem details Immun: UTD | Due Deworm: UTD | Due Vit A: UTD | Due Norm | Problem details
health: health: health:
On TB Y N
TB Rx On TB Y N
TB Rx On TB Y N
TB Rx
(months) TB Screen: Cough | TB Contact | Fever | Not growing well | Fatigue or playing less (months) TB Screen: Cough | TB Contact | Fever | Not growing well | Fatigue or playing less (months) TB Screen: Cough | TB Contact | Fever | Not growing well | Fatigue or playing less
Rx duration Rx duration Rx duration
Next HIV Next HIV Next HIV
HIV status: Known pos | Neg last test | Unkn Today | Other dd/mm/yyyy On IPT Y N N/A HIV status: Known pos | Neg last test | Unkn Today | Other dd/mm/yyyy On IPT Y N N/A HIV status: Known pos | Neg last test | Unkn Today | Other dd/mm/yyyy On IPT Y N N/A
test due: test due: test due:
Duration on Next VL Duration on Next VL Duration on Next VL
(months) date On Bactrim Y N N/A Duration on IPT months (months) date On Bactrim Y N N/A Duration on IPT months (months) date On Bactrim Y N N/A Duration on IPT months
current ART: test due: current ART: test due: current ART: test due:
Y N Condoms Y N Y N Condoms Y N Y N Condoms Y N
Caregiver

Mother: Well N/A

HIV: Known pos | Neg last test | Test due FP: UTD | Due type N/A
Mother: Well N/A
HIV: Known pos | Neg last test | Test due FP: UTD | Due type N/A
Mother: Well N/A
HIV: Known pos | Neg last test | Test due FP: UTD | Due type N/A
used used used
TB Y N Substance abuse Y N Psychosocial risk Y N details TB Y N Substance abuse Y N Psychosocial risk Y N details TB Y N Substance abuse Y N Psychosocial risk Y N details
Caregiver: Mother | Other Caregiver: Mother | Other Caregiver: Mother | Other

Time of consultation: Routine care: Immunise | Vit A | Deworm Time of consultation: Routine care: Immunise | Vit A | Deworm Time of consultation: Routine care: Immunise | Vit A | Deworm
History & Examination

Other IMCI: Measles | Ear problems | Sore throat | Other Other IMCI: Measles | Ear problems | Sore throat | Other Other IMCI: Measles | Ear problems | Sore throat | Other

Assessment / Diagnosis / Problem List Management / Medication / Supplements Assessment / Diagnosis / Problem List Management / Medication / Supplements Assessment / Diagnosis / Problem List Management / Medication / Supplements
Assessment & management

1 1 1

2 2 2

3 3 3

4 4 4

ART med(s) Duration ART med(s) Duration ART med(s) Duration

Referral Y N details Y N ART prescribed Referral Y N details Y N ART prescribed Referral Y N details Y N ART prescribed
change: Prescribed change: Prescribed change: Prescribed

Counselling/ Health Education: details / record on counselling stationery Updated RTHB Y N Counselling/ Health Education: details / record on counselling stationery Updated RTHB Y N Counselling/ Health Education: details / record on counselling stationery Updated RTHB Y N

Counselling Consent Name: Signature: Parent | Counselling Consent Name: Signature: Parent | Counselling Consent Name: Signature: Parent |
HIV test | Other procedure type Y N Y N HIV test | Other procedure type Y N Y N HIV test | Other procedure type Y N Y N
given for given: Caregiver given for given: Caregiver given for given: Caregiver
POS | NEG POS | NEG Write test details POS | NEG POS | NEG POS | NEG POS | NEG Write test details POS | NEG POS | NEG POS | NEG POS | NEG Write test details POS | NEG POS | NEG
CHILD: HIV Test screening confirmatory overpage
MOM: Rapid HIV Test screening confirmatory
CHILD: HIV Test screening confirmatory overpage
MOM: Rapid HIV Test screening confirmatory
CHILD: HIV Test screening confirmatory overpage
MOM: Rapid HIV Test screening confirmatory
Investigations

VL result TST POS | NEG X-rays Norm | Abn (enter details on back of outer) VL result TST POS | NEG X-rays Norm | Abn (enter details on back of outer) VL result TST POS | NEG X-rays Norm | Abn (enter details on back of outer)

Urine dipstix result Urine MC & S result Urine dipstix result Urine MC & S result Urine dipstix result Urine MC & S result

Other test: type result Other test: type result Other test: type result Other test: type result Other test: type result Other test: type result Other test: type result Other test: type result Other test: type result

BCG RV1 OPV1 HX1 PCV1 HX2 RV2 PCV2 HX3 M1 PCV3 HX4 M2 BCG RV1 OPV1 HX1 PCV1 HX2 RV2 PCV2 HX3 M1 PCV3 HX4 M2 BCG RV1 OPV1 HX1 PCV1 HX2 RV2 PCV2 HX3 M1 PCV3 HX4 M2
Data elements

FImm Vit A DeW EBF EBF14 MAM SAM FdSup TD1 TD2 HPV1 HPV2 FImm Vit A DeW EBF EBF14 MAM SAM FdSup TD1 TD2 HPV1 HPV2 FImm Vit A DeW EBF EBF14 MAM SAM FdSup TD1 TD2 HPV1 HPV2
Other Other Other

DD DND Pneu ASTHv HIVv TBv TBs TBsHIV TBcASx TBSx IPTeHIV TBcIPTi IPTiHIV DD DND Pneu ASTHv HIVv TBv TBs TBsHIV TBcASx TBSx IPTeHIV TBcIPTi IPTiHIV DD DND Pneu ASTHv HIVv TBv TBs TBsHIV TBcASx TBSx IPTeHIV TBcIPTi IPTiHIV

Appt Ref Disch. OHv EPILv MHv Appt Ref Disch. OHv EPILv MHv Appt Ref Disch. OHv EPILv MHv
Allied health Allied health Allied health Allied health Other Other Other Allied health Allied health Allied health Allied health Other Other Other Allied health Allied health Allied health Allied health Other Other Other

PN DR OHP Allied HP Other: Reason(s) for PN DR OHP Allied HP Other: Reason(s) for PN DR OHP Allied HP Other: Reason(s) for
Allied profession Job type/title Allied profession Job type/title Allied profession Job type/title
next visit: next visit: next visit:

Name: Name: Name:

Date of next Date of next Date of next
visit: visit: visit:
SANC/HPCSA no. SANC/HPCSA no. SANC/HPCSA no.
Date captured: Date captured: Date captured:
v.201905

Clerk (sign): Clerk (sign): Clerk (sign):

Signature: Signature: Signature:
Road to Health Booklet Click here to access/download;Figure;Additional File 4.pdf
Observation guide-Non Clinical Areas Click here to access/download;Figure;Additional File 5.pdf

Additional File 5
Observation Guide-Non-Clinical Areas
V1.0 13/07/2017

PACK CHILD Study

Ethnographic Observations

Observations of Non-Clinical Areas

o What is the layout of the clinic? How is the area you are observing designed?
o Which staff are working? Numbers and different types.
o How are patients accessing care? Are they just turning up?
o What gatekeepers are there? Reception staff? What conversations are patients
having with staff in order to access care for their child?
o Are any procedures or protocols being followed?
o How are patients managed when they arrive? Is there any face to face triage?
o Can you track how individual patients are managed and treated? Are they having just
one consultation or several?
o Note down any interesting quotes, particularly any points of tension between
staff/patients.
PACK Child Training Programme and Cascade Model Click here to access/download;Figure;Additional file 6.pdf

PACK Child Training Programme and Cascade Model

Phase 1 2 3 Training
Master
Trainers

Nine sessions
Facility
delivered over
Trainers five days

Nine sessions
Clinics &
delivered
staff weekly
Summary 1. Introductory activity
of 2. Introduce routine care (practise integrating routine care and a symptom)
training 3. Practise integrating routine care & symptom
sessions 4. Growth activity
5. Introduction to the young infant ≤ 2 months (documentation)
6. Health system strengthening session
7. Diagnosing long term health conditions
8. TB
9. HIV