Formative Study Of The Implementation Of The Practical Approach To Care Kit In Brazil (PACK Brazil) / Estudo Formativo da Implementação do Practical Approach to Care Kit no Brasil (PACK Brasil)

Vanessa Fernandes Davies, Daniela Alba Nickel, Elis Roberta Monteiro, Tatiane Baratieri, Jorge Ernesto Sergio Zepeda, Maria Cristina Marino Calvo, Sonia Natal


Introduction: The Practical Approach to Care Kit (PACK) is a comprehensive clinical practice guideline created to qualify health professionals at primary care level. The objective of this research is to present the formative study of the initial implementation of the PACK in Brazil. Methodological Path: Qualitative study that used in-depth interviews, questionnaires and focus groups with the trainers responsible for introducing the PACK in the local health clinics. To analyse the data, a thematic matrix technique was used. Results: Four in-depth interviews were conducted; 22 trainers answered the questionnaires and 15 trainers participated in two focus groups. Four themes were identified: 1. Expectations / Feelings regarding the PACK and its training; 2. Use of the PACK; 3. After the PACK; 4. Suggestions. Final Considerations: Participants were very enthusiastic about the implementation of the PACK. Some effects of the training on health professionals were noted in relation to the use of the protocol, such as: it appears to have been more widely used by doctors and nurses, who are not only accustomed to the routine of teaching and research, but who often have a close professional relationship. In addition, the results of this study highlighted important issues that need to be explored in order to understand the implementation of the PACK, such as factors related to behaviour change in individual clinical practice and care sharing.


Introduction: The Practical Approach to Care Kit (PACK) is a comprehensive clinical practice guideline created to qualify health professionals at primary care level. The objective of this research is to present the formative study of the initial implement

Full Text:



Pettigrew LM, Maesenee JD, Anderson MIP, Essuma A, Kidd MR, Haines. A Primary health care and the Sustainable Development Goals. Lancet. 2015; 386(28): 2119- 2121.

LaRocca R, Yost J, Dobbins M, Ciliska D, Butt M. The effectiveness of knowledge translation strategies used in public health: a systematic review. BMC Public Health. 2012 Sep 7;12(1):751.

Ward V, House A, Hamer S. Developing a framework for transferring knowledge into action: a thematic analysis of the literature. J Health Serv Res Policy. 2009 Jul 1;14(3):156–64.

Fairall L, Bateman E, Cornick R, Faris G, Timmerma V, Folb N, Bachman M, Zwarenstein M, Smith R. Innovating to improve primary carein less developed countries: towards a global model. BMJ Innov. 2015; doi:10.1136/bmjinnov-2015-000045.

Knowledge Translation Unit, 2014. http:// . Acessed 1 Apr 2018.

Fairall LR, Zwarenstein M, Bateman ED, Lombard C, Majara BP, Joubert G, English RG, Bheekie A, Rensburg DV, Mayers P, Peters AC, Chapman RD. Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomised controlled trial. BMJ. 2005; 331:750–754.

Zwarenstein M, Fairall LR, Lombard C, Mayers P, Bheekie A, English RG, Lewin S, Bachmann MO, Bateman E. Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial. BMJ. 2011; doi: 10.1136/bmj.d2022.

Bachmann MO, Fairall LR, Lombard C, Timmerman V, van der Merwe S, Bateman ED, Zwarenstein M. Effect on tuberculosis outcomes of educational outreach to South African clinics during two randomised trials. Int J Tuberc Lung Dis. 2010; 14(3): 311-317.

Fairall L, Bachmann MO, Lombard C, Timmerman V, Uebel K, Zwarenstein M, Boulle A, Georgeu D, Colvin CJ, Lewin S, Faris G, Cornick R, Drape B, Tshabalal M, Kotze I, Vuuren CV, Steyn D, Chapman R, Batemanb E. Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised trial. Lancet. 2012; doi: 10.1016/S0140-6736(12)60730-2.

Fairall L, Bachmann MO, Zwarenstein M, Bateman ED, Niessen LW, Lombard C, Majara B, English R, Bheekie A, van Rensburg D, Mayers P, Peters A, Chapman R. Cost-effectiveness of educational outreach to primary care nurses to increase tuberculosis case detection and improve respiratory care: economic evaluation alongside a randomised trial. Trop Med Int Health. 2010; 15(3):277-286.

Stein J, Lewin S, Fairall L, Mayers P, English R, Bheekie A, Bateman E, Zwarenstein M. Building capacity for antiretroviral delivery in South Africa: a qualitative evaluation of the PALSA PLUS nurse training programme. BMC Health Serv Res. 2008; doi: 10.1186/1472-6963-8-240.

Georgeu D, Colvin CJ, Lewin S, Fairall L, Bachmann MO, Uebel K, Zwarenstein M, Draper B, Bateman ED. Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial. Implement Sci. 2012; doi: 10.1186/1748-5908-7-66.

Prefeitura de Florianópolis. Ministério da Saúde oficializa: Floripa é 100%. 2015.¬i=13824. Accessed 05 Apr 2018.

Prefeitura de Florianópolis. Capital é a melhor do país em atenção básica à saúde. 2018.¬i=12986. Accessed 05 Apr 2018.

Ritchie J & Lewis J. Carrying out qualitative analysis. In: Qualitative Research Practice – A Guide for Social Students and Researchers. London: Sage Publications, 2003. p.220-262.

Armstrong K, Kendall E. Translating knowledge into practice and policy: the role of knowledge networks in primary health care. Health Inf Manag. 2010; 39(2):9-17.

Thompson GN, Estabrooks CA, Degner LF. Clarifying the concepts in knowledge transfer: a literature review. J Adv Nurs. 2006; 53(6):691–701.

Graham H, Tokhi M, Edward A, Salehi AS, Turkmani S, Duke T, Bartlett L. Use of clinical guidelines: perspectives from clinicians in paediatric and maternity hospitals in Kabul, Afghanistan. East Mediterr Health J. 2015; 21(2):100-110.

Davis D, Evans M, Jadad A, Perrier L, Rath D, Ryan D, Sibbald G, Straus S, Rappolt S, Wowk M, Zwarenstein M. The case for knowledge translation: shortening the journey from evidence to effect. BMJ. 2003; 327(7405):33-35.

Yazdani M, Sabetian G, Ra'ofi S, Roudgari A, Feizi M. A comparative study of teaching clinical guideline for prevention of ventilator-associated pneumonia in two ways: face-to-face and workshop training on the knowledge and practice of nurses in the intensive care unit. J Adv Med Educ Prof. 2015; 3(2): 68–71.

Blacklock C, Bradley DCG, Mickan S, Willcox M, Roberts N, Bergstrom A, Mant D. Impact of contextual factors on the effect of interventions to improve health worker performance in Sub-Saharan Africa: review of randomized clinical trials. PLoS One. 2016; doi: 10.1371/journal.pone.0145206.

Rustagi AS, manjate RM, Gloyd S, John-Stewart G, Micek M, Gimbel S, Sherr K. Perspectives of key stakeholders regarding task shifting of care for HIV patients in Mozambique: a qualitative interview-based study with Ministry of Health leaders,clinicians, and donors. Hum Resour Health.2015; doi: 10.1186/s12960-015-0009-3.

Sodhi S, Banda H, Kathyola D, Burciul B, Thompson S, Joshua M, Baterman E, Fairall L, Martiniuk A, Cornick R, Faris G, Draper B, Mondiwa M, Katengesa E, Sanudi L. Zwarenstein M, Schull MJ. Evaluating a streamlined clinic tool and educational outreach intervention for health care workers in Malawi: the PALM PLUS case study. BMC Int Health Hum Rights.2011;doi: 10.1186/1472-698X-11-S2-S11.

O'Malley G, Asrat L, Sharma A, Hamunime N, Stephanus Y, Brandt L, Ali D, Kaindjee-Tjituka F, Natanael S, Gweshe J, Feldacker C, Shihepo E. Nurse task shifting for antiretroviral treatment services in Namibia: implementation research to move evidence into action. PLoS One. 2014;doi: 10.1371/journal.pone.0092014.

Davies NECG, Homfray M, Venables EC. Nurse and manager perceptions of nurse initiated and managed antiretroviral therapy (NIMART) implementation in South Africa: a qualitative study. BMJ open. 2013;doi: 10.1136/bmjopen-2013-003840.

Georgeau D, Colvin CJ, Lewin S, Fairall L, Bachmann MO, Uebel K, Zwarenstein M, Draper B, Bateman ED. Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRECH trial. Implement Sci.2012;doi: 10.1186/1748-5908-7-66.

Wong G, Greenhalgh T, Westhorp G, Pawson R. Realist methods in medical education research: what are they and what can they contribute?: Realist methods in medical education research. Med Educ. 2012 Jan;46(1):89–96.

Moreno EM, Moriana JA. Clinical guideline implementation strategies for common mental health disorders. Rev.Psiquiatr Salud Ment.2016; doi:10.1016/j.rpsm.2015.09.001.

Topp SM, Abimbola S, Joshi R, Negin J. How to assess and prepare health systems in low-and middle-income countries for integration of services – a systematic review. Health Policy Plan.2018;doi: 10.1093/heapol/czx169.

Adedeji AR, Tumbo J, Govender I. Adherence of doctors to a clinical guideline for hypertension in Bojanala district, North-West Province, South Africa. Afr J Prm Health Care Fam Med. 2015; v7i1.776.

Martins SM, Saibe-Filho W, Tonioli LP, Pfingesten LE, Braz PD, McDonnell J, Williams S, do Carmo D, de Sousa JC, Pinnock H, Stelmach. Implementation of “matrix support” (collaborative care) to reduce asthma and |COPD referrals and improve primary care management in Brazil: a pilot observational study. NPJ Prim Care Respir Med.2016;doi: 10.1038/npjpcrm.2016.47.

Heaton J, Day J, Britten N. Inside the “balck box” of a knowledge translations program in applied health research. Qual Health Res.2015; doi: 10.1177/1049732315580104

Mickan S, Wenke R, Weir K, Bialocerkowski A, Noble C. Strategies for research engagement of clinicians in allied health (STRETCH): a mixed methods research protocol. BMJ open.2017; doi: 10.1136/bmjopen-2016-014876.



  • There are currently no refbacks.