Improving community case management of diarrhoea and pneumonia in district Badin, Pakistan through a cluster randomised study—the NIGRAAN trial protocol

Abstract

BackgroundDiarrhoea and pneumonia contribute 30% of deaths in children under 5 in Pakistan. Pakistan’s Lady Health Workers Programme (LHW-P) covers about 60% of the population but has had little impact in reducing morbidity and mortality related to these major childhood killers. An external evaluation of the LHW-P suggests that lack of supportive supervision of LHWs by lady health supervisors (LHSs) is a key determinant of this problem. Project NIGRAAN aims to improve knowledge and skills of LHWs and community caregivers through supervisory strategies employed by LHSs. Ultimately, community case management (CCM) of childhood pneumonia and diarrhoea will improve.Methods/DesignNIGRAAN is a cluster-randomised trial in District Badin, Pakistan. There are approximately 1100 LHWs supervised by 36 LHSs in Badin. For this study, each LHS serves as a cluster. All LHSs working permanently in Badin who regularly conduct and report field visits are eligible. Thirty-four LHSs have been allocated to either intervention or control arms in a ratio of 1:1 through computer-generated simple randomisation technique. Five LHWs from each LHSs are also randomly picked. All 34 LHSs and 170 LHWs will be actively monitored. The intervention consists of training to build LHS knowledge and skills, clinical mentorship and written feedback to LHWs. Pre- and post-intervention assessments of LHSs, LHWs and community caregivers will be conducted via focus group discussions, in-depth interviews, knowledge assessment questionnaires, skill assessment scorecards and household surveys.Primary outcome is improvement in CCM practices of childhood diarrhoea and pneumonia and will be assessed at the cluster level.DiscussionNIGRAAN takes a novel approach to implementation research and explores whether training of LHSs in supervisory skills results in improving the CCM practices of childhood diarrhoea and pneumonia. No significant harm to participants is anticipated. The enablers and barriers towards improved CCM would provide recommendations to policymakers for scale up of this intervention nationally and regionally.Trial registrationNIGRAAN is registered with the ‘Australian New Zealand Clinical Trials Registry’. Registration Number: ACTRN12613001261707

Improving community health worker performance through supportive supervision: a randomised controlled implementation trial in Pakistan

“…Nigraan (named for an Urdu word meaning supervisor), a cluster randomised controlled trial, was conducted in Badin district in Pakistan . Badin is predominantly rural, spans 6726 km 2 and has a population of 1.35 million.…”

Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart

“…A notable strength of this is study is that despite the long timespan of this analysis (1989-2014), about a third of the study staff were involved in both the initial study and more recent follow-up and were able to collect comparable information during both periods. However, the supervision and support given to the study staff was more comprehensive in Study 1, which likely had a positive impact on health worker performance as suggested by other studies [40,46]. Similarly, in Study 1 community members could more easily meet with a member of the study team if their child became sick in between visits, but in Study 2…”

Challenges in Implementing a Community Based Trial in a Rural Pakistani District: Lessons Learnt from Project NIGRAAN

“…The main study outcome was improvement of CCM for childhood diarrhea and pneumonia. Further details of the study are published elsewhere [17].…”

“…Independent studies including external evaluations of the program shed some light on the factors responsible for this poor outcome. These are poor clinical mentorship and supervisory skills of Lady Health Supervisors (LHS) and dysfunctional supervisory links between LHSs and LHWs [11,[13][14][15][16][17][18]. In order to bridge these supervisory gaps, the Aga Khan University Pakistan in collaboration with health department, government of Sindh introduced an IR project called NIGRAAN.…”