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

Fauziah Rabbani, Aftab Akbar Ali Mukhi, Shagufta Perveen, Xaher Gul, Saleem Perwaiz Iqbal, Shamim Ahmed Qazi, Iqbal Azam Syed, Khalid Hussain Shaikh, Wafa Aftab

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 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 1,100 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 LHS 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 LHS are also randomly picked. All 34 LHS 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 LHS, 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 community case management 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 LHS in supervisory skills results in improving the community case management 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.