CHWs (148) WHO releases first guideline on digital health interventions (15) PACK (Practical Approach to Care Kit) (6)

19 July, 2019

[*Note from HIFA moderator (Neil PW): Apologies, this message was originally sent on 13 July and got stuck in the system. We normally aim to process messages within 1-3 hours.]

Neil, I read the recommendation and your comments with great interest because we recently gained some practical experience about the use of a guide in paper and electronic forms in PHCs in Nigeria. I am glad to share the experience as carried in the report of the intervention for the benefit and information of members.

'Report on training of healthcare personnel in the use of the PACK Nigeria Adult (‘PNA’) guide in Ondo, Adamawa and Nasarawa states: February to September 2017. *Executive summary:*

Between February and September 52 Facility Trainers delivered PNA onsite inservice training to 354 primary care health clinician workers of all cadres ( junior community health extension workers; community health extension workers; community health practitioners, nurses; midwives; medical officers) in 51 facilities in the Ondo, Adamawa and Nasarawa states, supervised directly by 12 Master Trainers. PACK (Practical Approach to Care Kit) guide was introduced in digital / electronic form for the first time in a tablet (ePACK) during the Nigeria pilot in 2017. Below is the reported opinion of the users in PHC in the three pilot states on both the paper and electronic forms:

Comparison and preferences of book and tablet formats

Most participants in each state expressed a *preference for the electronic form*; 89% In Adamawa state, 75% in Ondo state and 67% in Nasarawa state. The expressed reasons for this preference were as follows:

*Advantages of the Book form* are: relative ease of navigation i.e. to find the relevant page; easy availability i.e. access to a copy of the guide was easier and ‘on the go’.

*Disadvantages of the Book form* are initial poor patient acceptability of staff using guide: Reference to a book was viewed by patients as an indication of lack of knowledge and expertise, and patients lost confidence, temporarily, in clinicians. Overall, using the book was considered more time-consuming initially, especially in referring to other pages. Rrespondents were concerned about lack of durability of the cover and paper of the book format.

*Advantages of the electronic form (ePACK):* In all three states, the tablet format was preferred. It was described as *efficient *and relatively *easier to use* (once mastered), and it takes only a few hours to master and be orientated. It was *more acceptable to patients* (they view an electronic medium as progressive and modern and it increased patient confidence in the clinician). There were instances where patients attended to by a PACK-using staff, went home and referred his / her family members and friends to ‘that clinic that uses ePACK (new device)’. The content is off-line so does not depend on internet connectivity and access. *Disadvantages of the tablet form (ePACK):* Respondents reported *technical challenges* and *operational limitations*. Technical challenges included the *need for batteries and charging* (a secure supply of electricity is not available in many areas), *security* (theft), breakage, and potential *abuse of the tablet* for other purposes. Operational limitations are *malfunction of the back-arrow* and *inability to hold (bookmark) previous pages* when moving to another. The ePACK is on average more expensive than the paper format. Recommendations

on both forms of PACK from focus groups:

All states preferred the electronic form of PNA. However participants recommended that initially *both forms (paper and electronic PACK) may be made available* in all clinics, and that the *number of tablets is increased need in a phased plan, as resources permit*. Additional suggestions were: (i) To publicise PNA and *create awareness of PNA* in communities to promote its use and scaled up, (ii) provision and use of *power banks* to charge the tablets, (iii) to *resolve technical difficulties* with the ‘back arrow ( boomerang arrow)’ key in the electronic form, and (iv) to use a *harder cover and more durable binding* on the book form to prevent damage and extend its usefulness.

Reference: Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South reference: Africa to Nigeria. BMJ Global Health Oct 2018, 3 (Suppl 5) e001079; DOI: 10.1136/bmjgh-2018-001079 ‘’

Joseph Ana.


*Africa Center for Clin Gov Research & Patient Safety*

*@ HRI West Africa Group - HRI WA*

*Publisher: Health and Medical Journals *

*8 Amaku Street Housing Estate, CalabarCross River State, Nigeria*

*Visit Website: <>E-mail



HIFA profile: Joseph Ana is the Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. In 2015 he won the NMA Award of Excellence for establishing 12-Pillar Clinical Governance, Quality and Safety initiative in Nigeria. He has been the pioneer Chairman of the Nigerian Medical Association (NMA) National Committee on Clinical Governance and Research since 2012. He is also Chairman of the Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. He is particularly interested in strengthening health systems for quality and safety in LMICs. He has written Five books on the 12-Pillar Clinical Governance for LMICs, including a TOOLS for Implementation. He established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria in 2007. Website: Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers.

Email: jneana AT