title: Improving community case management of diarrhoea and pneumonia in district Badin, Pakistan through a cluster randomised study--the NIGRAAN trial protocol.
abstract: BACKGROUND
  Diarrhoea 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
  NIGRAAN 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.
  
  
  CONCLUSIONS
  NIGRAAN 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.
  
  
  BACKGROUND
  NIGRAAN is registered with the 'Australian New Zealand Clinical Trials Registry'.
  
  
  BACKGROUND
  ACTRN12613001261707.
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Stadium Road, 3500, Karachi, 74800, Pakistan. fauziah.rabbani@aku.edu.
authors.forename: Fauziah
authors.initials: F
authors.lastname: Rabbani
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Stadium Road, 3500, Karachi, 74800, Pakistan. aftab.mukhi@aku.edu.
authors.forename: Aftab Akbar Ali
authors.initials: AA
authors.lastname: Mukhi
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Stadium Road, 3500, Karachi, 74800, Pakistan. shagufta.perveen@aku.edu.
authors.forename: Shagufta
authors.initials: S
authors.lastname: Perveen
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Stadium Road, 3500, Karachi, 74800, Pakistan. xgul@fulbrightmail.org.
authors.forename: Xaher
authors.initials: X
authors.lastname: Gul
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Stadium Road, 3500, Karachi, 74800, Pakistan. saleem.iqbal@aku.edu.
authors.forename: Saleem Perwaiz
authors.initials: SP
authors.lastname: Iqbal
authors.affiliation: Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland. qazis@who.int.
authors.forename: Shamim Ahmed
authors.initials: SA
authors.lastname: Qazi
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Stadium Road, 3500, Karachi, 74800, Pakistan. iqbal.azam@aku.edu.
authors.forename: Iqbal Azam
authors.initials: IA
authors.lastname: Syed
authors.affiliation: Department of Health, Government of Sindh, 6th floor, New Sindh Secretariat, Karachi, Pakistan. kmshaikh2007@yahoo.com.
authors.forename: Khalid Hussain
authors.initials: KH
authors.lastname: Shaikh
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Stadium Road, 3500, Karachi, 74800, Pakistan. wafa.aftab@aku.edu.
authors.forename: Wafa
authors.initials: W
authors.lastname: Aftab
mesh_terms: D000288:Administrative Personnel / Q000193:education / Q000706:statistics & numerical data; D017028:Caregivers / Q000193:education / Q000706:statistics & numerical data; D019090:Case Management / Q000592:standards*; D057189:Checklist; D002675:Child, Preschool; D002983:Clinical Competence / Q000592:standards; D016000:Cluster Analysis; D003153:Community Health Services / Q000592:standards*; D003625:Data Collection; D003695:Delivery of Health Care / Q000592:standards; D003967:Diarrhea / Q000628:therapy*; D006282:Health Personnel / Q000193:education / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007318:Inservice Training; D008331:Management Information Systems / Q000706:statistics & numerical data; D064691:Nurses, Community Health / Q000193:education / Q000706:statistics & numerical data; D010154:Pakistan; D011014:Pneumonia / Q000628:therapy*; D058996:Quality Improvement; D011795:Surveys and Questionnaires