Dataset Information

Addressing the quality and scope of paediatric primary care in South Africa: evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child).

ABSTRACT:

Background

Despite significant reductions in mortality, preventable and treatable conditions remain leading causes of death and illness in children in South Africa. The PACK Child intervention, comprising clinical decision support tool (guide), training strategy and health systems strengthening components, was developed to expand on WHO's Integrated Management of Childhood Illness programme, extending care of children under 5?years to those aged 0-13?years, those with chronic conditions needing regular follow-up, integration of curative and preventive measures and routine care of the well child. In 2017-2018, PACK Child was piloted in 10 primary healthcare facilities in the Western Cape Province. Here we report findings from an investigation into the contextual features of South African primary care that shaped how clinicians delivered the PACK Child intervention within clinical consultations.

Methods

Process evaluation using linguistic ethnographic methodology which provides analytical tools for investigating human behaviour, and the shifting meaning of talk and text within context. Methods included semi-structured interviews, focus groups, ethnographic observation, audio-recorded consultations and documentary analysis. Analysis focused on how mapped contextual features structured clinician-caregiver interactions.

Results

Primary healthcare facilities demonstrated an institutionalised orientation to minimising risk upheld by provincial documentation, providing curative episodic care to children presenting with acute symptoms, and preventive care including immunisations, feeding and growth monitoring, all in children 5?years or younger. Children with chronic illnesses such as asthma rarely receive routine care. These contextual features constrained the ability of clinicians to use the PACK Child guide to facilitate diagnosis of long-term conditions, elicit and manage psychosocial issues, and navigate use of the guide alongside provincial documentation.

Conclusion

Our findings provide evidence that PACK Child is catalysing a transition to an approach that strikes a balance between assessing and minimising risk on the day of acute presentation and a larger remit of care for children over time. However, optimising success of the intervention requires reviewing priorities for paediatric care which will facilitate enhanced skills, knowledge and deployment of clinical staff to better address acute illnesses and long-term health conditions of children of all ages, as well as complex psychosocial issues surrounding the child.

SUBMITTER: Murdoch J

PROVIDER: S-EPMC7257217 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Publications

Addressing the quality and scope of paediatric primary care in South Africa: evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child).

Murdoch Jamie J Curran Robyn R Cornick Ruth R Picken Sandy S Bachmann Max M Bateman Eric E Simelane Makhosazana Lungile ML Fairall Lara L

BMC health services research 20200529 1

<h4>Background</h4>Despite significant reductions in mortality, preventable and treatable conditions remain leading causes of death and illness in children in South Africa. The PACK Child intervention, comprising clinical decision support tool (guide), training strategy and health systems strengthening components, was developed to expand on WHO's Integrated Management of Childhood Illness programme, extending care of children under 5 years to those aged 0-13 years, those with chronic conditions ...[more]

PMID: 32471431

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Project description:BackgroundThe WHO's Integrated Management of Childhood Illness (IMCI) has resulted in progress in addressing infant and child mortality. However, unmet needs of children continue to present a burden upon primary healthcare services. The capacity of services and quality of care offered require greater support to address these needs by extending and integrating curative and preventive care for the child with a long-term health condition and the child older than 5, not prioritised in IMCI. In response to these needs, the PACK Child intervention was developed and piloted in October 2017-February 2019 in the Western Cape Province of South Africa. We report health worker and caregiver perspectives of the existing paediatric primary care context as well as the extent to which PACK Child functions to address perceived problems within the current local healthcare system.MethodsThis process evaluation involved 52 individual interviews with caregivers, 10 focus group discussions with health workers, 3 individual interviews with trainers, and 31 training observations. Interviews and focus groups explored participants' experiences of paediatric primary care, perspectives of the PACK Child intervention, and tensions with implementation in each context. Inductive thematic analysis was used to analyse verbatim interview and discussion transcripts.ResultsPerspectives of caregivers and health workers suggest an institutionalised focus of paediatric primary care to treating children's symptoms as acute episodic conditions. Health workers' reports imply that this focus is perpetuated by interactions between contextual features such as, IMCI policy, documentation-driven consultations, overcrowded clinics and verticalised care. Whilst these contextual conditions constrained health workers' ability to translate skills developed within PACK Child training into practice, the intervention initiated expanded care of children 0-13 years and those with long-term health conditions, enhanced professional competence, improved teamwork and referrals, streamlined triaging, and facilitated probing for psychosocial risk.ConclusionPACK Child appears to be catalysing paediatric primary care to address the broader needs of children, including long-term health conditions and the identification of psychosocial problems. However, to maximise this requires primary care to re-orientate from risk minimisation on the day of attendance towards a view of the child beyond the day of presentation at clinics.

Project description:Limiting or withdrawing nonbeneficial medical care is considered ethically responsible throughout most of critical care and medical ethics literature. Practically, however, setting limits to treatment is often challenging. We review the literature to identify best practices for using the definition of futility as an anchoring concept to aid the ethical practice of ICU clinicians.Data sourcesSource data were obtained from a PubMed literature review.Study selectionEnglish language articles were chosen based on relevance to medical futility ethics, end-of-life care in the ICU, or communication and conflict mitigation strategies.Data extractionIndependent evaluation of selected articles for recurrent content themes as relevant to our clinical case were compared among authors and based on consensus, quantitative and qualitative data from these sources were referenced directly.Data synthesisWhen life-sustaining treatment is unlikely to achieve a meaningful benefit such as symptom improvement, continued care may be discordant with the patient's goals. Institutional and cultural norms, unconscious biases, and difficulty with navigating conflicts all influence how un(comfortable) clinicians feel in setting limits to futile care. Defining futility in light of the patient's goals and values, focusing on outcomes rather than interventions, and being proactive in communication with families are the staples of medically meaningful critical care. Palliative measures should be framed affirmatively, and clinicians should be transparent about the limits of medicine.ConclusionsClinicians have an ethical obligation not to provide futile care. To practice accordingly, we must clearly understand the nature and forms of futility. Armed with this understanding, our discussions with family and surrogates in the ICU should fundamentally comprise 1) eliciting the patient's values and goals, 2) communicating which interventions serve those values and goals and which do not, and 3) offering only those interventions whose likely outcomes are in line with said values and goals.

Project description:The majority of paediatric femur fractures result from accidental trauma; however, it is important to consider non-accidental trauma, especially in pre-ambulatory children. We study whether irrelevant contextual information subconsciously influences conclusions of healthcare professionals with respect to whether observations provide evidence for non-accidental trauma. A survey with nine radiographs of femur shaft fractures was designed. Two different clinical histories (vignettes) with contextual information were designed, non-abuse versus abuse context. One of both vignettes was randomly assigned to the radiograph shown to the participant, followed by a question with a 5-point answer scale, which represents a verbal expression of the likelihood ratio of the fracture regarding a non-accidental versus accidental cause. Participants were medical residents and staff members of different specialties from several Dutch hospitals. A total of 172 participants responded. The reported evidential strength of the vignettes with a non-abuse context was 0.19 (n = 784; 95%CI 0.10-0.28) and for the abuse context 0.94 (n = 764; 95%CI 0.86-1.02; p < 0.001). Women reported a stronger evidential strength than men, but both were influenced by context. Emergency department and paediatric doctors were more likely to decide that non-accidental trauma was the cause; paediatric radiologists were the least likely. Experience in years of practice and current function did not prevent participants from being bias.Conclusion: This study shows that the interpretation of medical results by healthcare professionals can be influenced by contextual information, such as low income and marital status, which are irrelevant to the decision as to whether abuse might have occurred. Given the same information about an injury, women, emergency department and paediatric doctors were more likely to decide that non-accidental trauma was the cause, while paediatric radiologists were least likely to decide this outcome. It is important to prevent contextual influence as much as possible, by recognizing it and implementing a management contextual information procedure. What is Known: • Contextual information is of possible influence on healthcare professionals in identifying non-accidental trauma. • Increased working experience is thought to be protective against this influence. What is New: • Contextual information influenced the interpretation of medical results by healthcare professionals regardless of work experience. • The interpretation of medical results by healthcare professionals is influenced by both affirmative and negative contextual information.

Project description:BackgroundFollowing visible successes on a wide range of predictive tasks, machine learning techniques are attracting substantial interest from medical researchers and clinicians. We address the need for capacity development in this area by providing a conceptual introduction to machine learning alongside a practical guide to developing and evaluating predictive algorithms using freely-available open source software and public domain data.MethodsWe demonstrate the use of machine learning techniques by developing three predictive models for cancer diagnosis using descriptions of nuclei sampled from breast masses. These algorithms include regularized General Linear Model regression (GLMs), Support Vector Machines (SVMs) with a radial basis function kernel, and single-layer Artificial Neural Networks. The publicly-available dataset describing the breast mass samples (N=683) was randomly split into evaluation (n=456) and validation (n=227) samples. We trained algorithms on data from the evaluation sample before they were used to predict the diagnostic outcome in the validation dataset. We compared the predictions made on the validation datasets with the real-world diagnostic decisions to calculate the accuracy, sensitivity, and specificity of the three models. We explored the use of averaging and voting ensembles to improve predictive performance. We provide a step-by-step guide to developing algorithms using the open-source R statistical programming environment.ResultsThe trained algorithms were able to classify cell nuclei with high accuracy (.94 -.96), sensitivity (.97 -.99), and specificity (.85 -.94). Maximum accuracy (.96) and area under the curve (.97) was achieved using the SVM algorithm. Prediction performance increased marginally (accuracy =.97, sensitivity =.99, specificity =.95) when algorithms were arranged into a voting ensemble.ConclusionsWe use a straightforward example to demonstrate the theory and practice of machine learning for clinicians and medical researchers. The principals which we demonstrate here can be readily applied to other complex tasks including natural language processing and image recognition.

Project description:BackgroundSuriname is a uppermiddle-income country with a relatively high prevalence of preventable pregnancy complications. Access to and usage of high-quality maternity care services are lacking. The implementation of group care (GC) may yield maternal and child health improvements. However, before introducing a complex intervention it is pivotal to develop an understanding of the local context to inform the implementation process.MethodsA context analysis was conducted to identify local needs toward maternity and postnatal care services, and to assess contextual factor relevant to implementability of GC. During a Rapid Qualitative Inquiry, 63 online and face-to-face semi-structured interviews were held with parents, community members, on-and off-site healthcare professionals, policy makers, and one focus group with parents was conducted. Audio recordings were transcribed in verbatim and analysed using thematic analysis and Framework Method. The Consolidated Framework for Implementation Research served as a base for the coding tree, which was complemented with inductively derived codes.ResultsTen themes related to implementability, one theme related to sustainability, and seven themes related to reaching and participation of the target population in GC were identified. Factors related to health care professionals (e.g., workload, compatibility, ownership, role clarity), to GC, to recipients and to planning impact the implementability of GC, while sustainability is in particular hampered by sparse financial and human resources. Reach affects both implementability and sustainability. Yet, outer setting and attitudinal barriers of health professionals will likely affect reach.ConclusionsMulti-layered contextual factors impact not only implementability and sustainability of GC, but also reach of parents. We advise future researchers and implementors of GC to investigate not only determinants for implementability and sustainability, but also those factors that may hamper, or facilitate up-take. Practical, attitudinal and cultural barriers to GC participation need to be examined. Themes identified in this study will inspire the development of adaptations and implementation strategies at a later stage.

Dataset Information

Addressing the quality and scope of paediatric primary care in South Africa: evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child).

Background

Methods

Results

Conclusion

Publications

Addressing the quality and scope of paediatric primary care in South Africa: evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child).

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