Table 1

PACK guide features

FeatureRationale for featureExample
Clinical approach
Symptom basedPatients usually present with symptoms, not diagnoses, so this takes the patient’s presentation as the starting point. Unlike a guideline with a disease entry point, it can prompt screening for and diagnosis of chronic conditions.Each symptom is arranged on its own page. The ‘Collapse’ page prompts consideration of eight ‘chronic conditions’ which may still be undiagnosed or uncontrolled. These include ischaemic heart disease, diabetes, stroke, a mental health condition, epilepsy and pregnancy.
Syndromic approach to assessment and managementEnsures that the user with limited clinical skill and experience will still be prompted to manage the patient safely, even in the absence of a certain diagnosis, while recognising limited capacity of most LMIC primary care facilities to confirm a diagnosis with available tests and investigations.The syndromic approach may lead to a ‘likely’ diagnosis and appropriate management plan. For patients needing urgent care, it may not define a diagnosis but rather urgent empirical management for potentially life-threatening conditions (eg, meningitis) and immediate referral.
History taking, examination and investigations incorporated into clinical approachAvoiding vague prompts like ‘Take a history’ or ‘Do a thorough examination,’ PACK elicits those details relevant to the particular symptom or condition and provides a clear response to each.Headache page algorithm: ‘Is headache disabling and recurrent with nausea or light/noise sensitivity, that resolves completely? If Yes: Migraine likely.’
Content focuses on what actions the clinician should takePACK avoids explanations of pathophysiology, public health prioritisation or pharmacodynamics as it aims to support the busy clinician in a consultation and needs to be as brief as possible.The ‘Hypertension: diagnosis’ page does not provide details of the prevalence or pathophysiology of hypertension, but instead gives clear instructions on how to take a blood pressure correctly, how to interpret the result and when to repeat it if raised.
Language style
ConciseEnables regular reference in busy primary care consultations and allows a comprehensive approach in a 120-page guide.
Plain language, avoids medical jargonEmpowers use in clinician with limited skill or experience. Makes health knowledge more accessible.‘Difficulty breathing’ instead of ‘dyspnoea’
Addresses user in the active voiceClearly places responsibility for action with the clinician.‘Test cholesterol’ instead of ‘Cholesterol tests should be done in all patients.’
Focuses on the individual patientIt ensures a focus on the individual patient by dealing with only the patient in the current consultation, not all patients.On the Stroke page: ‘Help the patient to manage his/her CVD risk’ instead of ‘Advise all patients with stroke to manage their cardiovascular disease (CVD) risk.’
Standard phrasingStandard phrasing for common management, screening and referral recommendations increases their familiarity across the guide.
  • Depression screen: ‘In the past month, has patient: (1) felt down, depressed, hopeless or (2) felt little interest or pleasure in doing things?’

  • Three different referral prompts: ‘urgent’, ‘same week’ and ‘next appointment’.

Formatting and design
Clinical approach to symptoms arranged in algorithmsMakes the clinical decision-making process explicit and prompts decision-making in a stepwise fashion. Unlike recommendations presented in narrative format, all possible responses to key questions and findings are presented.See figure 3.
Algorithms flow from top to bottomReaders approach text from the top and work down; it also provides equal weighting to decision-making in an algorithm. This is different from WHO guidance, typically arranged from left to right.See figure 3.
Standard format of pagesThis builds familiarity with the approach and can help establish a pattern to a clinical consultation, especially useful when a patient has several symptoms or conditions.
  • The starting point of each symptom page is to identify whether the patient needs urgent attention.

  • A three-step ‘Assess, Advise, Treat’ framework standardises ‘Routine Care’ of the patient with a chronic condition. See figure 4.

ChecklistsProvides a very simple, yet systematic approach to routine care for the patient with a chronic condition adopting a health systems approach which defines ‘chronic’ as anything that requires repeated, planned visits to care.Checklists can form the main structure of pages for chronic conditions using the ‘Assess, Advise, Treat’ framework (figure 4) but can also be embedded in boxes of content like warning signs for a headache that may warrant immediate referral.
Colour coding indicates scope of practice, urgency and content sectionsColour breaks the monotony of a monochrome design. Colour coding aids efficient use and can enhance recommendations.
  • Red-outlined boxes identify the patient needing urgent attention.

  • Chronic condition sections are colour coded.

  • Medication colour coded for level of prescriber.

Illustrations and photographsUseful to guide likely diagnosis, provide prompts for shared decision-making with a patient and to demonstrate a management option to a patient.
  • ‘How to syringe an ear’; ‘How to use an inhaler with a spacer’.

  • Prompts for health education content like lifestyle interventions to reduce cardiovascular risk.

  • Photographs show common skin, ear and genital problems.

Arrows guide the user to relevant pagesArrows prompt the user to consult several relevant pages, enabling integrated care within one consultation.
  • Headache page guides the user to the HIV diagnosis page for an HIV test if repeated sinusitis-related headaches occur.

  • The diabetes routine care page sends the user to the routine hypertension care page to manage the comorbidity.

  • A direct arrow indicates that the user should continue directly to another page: a return arrow advises returning to the original page after visiting the new page.

Hard copy features
Ring boundMakes page turning and place holding easier.
Printed on durable paperAids regular use for at least a year until the next update.
Sections demarcated with tabsFacilitates finding the sections easily.
Content limited to 1–5 pages per symptom or conditionTo limit the guide’s size and to maintain a focus on priority common conditions for LMIC primary care.An approach to most symptoms is contained in one page; the chronic condition sections span 1–5 pages depending on the scope required for LMIC primary care—‘HIV routine care’ has 5 pages, dementia 1.
  • LMIC, low/middle-income country; PACK, Practical Approach to Care Kit.