None listed
Conditions
Brief summary
Background: LHWs, in Pakistan play an important role as first line community care givers in the home especially for child health. While they have helped improve uptake of some health services, such as family planning and antenatal care, in rural areas of Pakistan, their impact on increasing coverage of pneumonia and diarrhea treatment interventions has been minimal. Despite the deployment of over 100,000 LHWs the under-five mortality rate in Pakistan is stagnant. The main deficiencies of the LHW program are weak LHW knowledge and skills and deficient supervision. There is evidence that increased supervisory competence and supportive supervision improves knowledge, skills and overall performance of junior staff. We, therefore, infer that identifying appropriate strategies to strengthen existing supportive supervision through a stakeholder perception analysis followed by a specific intervention addressing the lack of supportive supervision by lady health supervisors (LHS) can result in expanding coverage and quality of case management of diarrhea and pneumonia in children under five years of age. Study Goal: To explore an optimum strategy for structured supportive supervision of LHWs and demonstrate how this intervention can or cannot enhance LHW performance for improving health of children under five and understand the barriers and enablers to implementation and scale up of this strategy in Pakistan’s context. Study Objectives: 1. To assess stakeholder (decision makers, implementers, LHSs, LHWs) perspectives regarding an evidence-based supervisory intervention to improve LHW performance. 2. To study the effect of promoting context- specific “Structured Supportive Supervision (SSS)” of LHWs by LHS for reducing pneumonia and diarrhea in children under five. 3. To understand the enablers and barriers for SSS implementation and recommend strategies for scaling up the intervention in the context of Pakistan. Study Design and Methods: Project NIGRAAN is a mixed methods study using two types of mixed methods (i) exploratory sequential and (ii) embedded. The study will be implemented in three phases. Phase I will be pre-intervention formative research to build the optimized supervisory intervention. Using the qualitative research approach, FGDs and key informant interviews will be conducted with LHWs, LHS, Implementers and Policy makers and the results will be fed into an evidence-based intervention. Phase II of the study will test this supervisory intervention using quantitative methods including baseline-endline household survey, pre and post intervention LHS and LHW knowledge scoring and independently evaluated structured skill assessment. Concurrent FGDs and KI interviews during Phase II will explore stakeholder experiences of the intervention. Phase III of the study will employ FGDs and KI Interviews to explore stakeholder perspectives regarding scaling up of the intervention. The study will be conducted in District Badin, in Sindh with LHS, LHW, Primary caregivers, implementers and policy makers as study participants Expected Outcomes: 1. Improved knowledge, skills and supervisory processes among LHSs for CCM of pneumonia and diarrhoea in children under five. 2. Improvement in LHW knowledge, skills and performance as a result of structured supportive supervision by LHSs. 3. Increased knowledge of community caregivers about the presence and role of LHWs for CCM of pneumonia and diarrhoea in children under five
Interventions
Project NIGRAAN is a two year long community based intervention trial aiming to explore whether structured supportive supervision by LHS of LHWs results in improved health of children under five.
The intervention consists of:
a. Training
i. Develop knowledge and skills of LHSs for Community Case Management (CCM) of pneumonia and diarrhoea in children under five
ii. Develop clinical mentoring skills of LHSs
iii. Strengthen supportive feedback skills of LHSs
b. Supervisory t
Project NIGRAAN is a two year long community based intervention trial aiming to explore whether structured supportive supervision by LHS of LHWs results in improved health of children under five. The intervention consists of: a. Training i. Develop knowledge and skills of LHSs for Community Case Management (CCM) of pneumonia and diarrhoea in children under five ii. Develop clinical mentoring skills of LHSs iii. Strengthen supportive feedback skills of LHSs b. Supervisory tools i. Modified Supervisory Checklist: ii. The Supervisor’s Tally Sheet for Compilation of Quality of Case Management iii. LHS Feedback Card for Individual LHWs. LHSs would be provided training in a 4 day workshop during which a ‘Training Consultant’—taken on board for this particular task—would facilitate them in terms of improving their theoretical understanding of the approaches for community case management of Diarrhoea and Pneumonia, clinical mentoring skills (LHSs skills in assisting LHWs improve their case management skills) and supervisory skills (LHSs skills in providing verbal and written feedback to improve LHW performance and case management practices). The face to face learning would be complemented by hands on training and practical exercises in a simulated environment as well as in the real life settings. The curriculum and relevant content for the training package (which actually is the intervention—The NIGRAAN Training Package—to be finalized after completion of the qualitative/formative phase of the study. The findings from this phase would identify the gaps in the current level of understanding of LHWs and LHSs in regard to community case management of diarrhoea and pneumonia as well as clinical mentoring and supervisory skills of LHSs. The instructional methodologies used during the training would be interactive lectures complemented with audio-visual aids/videos (to be sourced through WHO), role plays, problem based learning in the form of practical exercises and group work. All these approaches coupled with the relevant content will help LHSs refine their understanding of community case management of diarrhoea and pneumonia as well as clinical mentoring and supervisory skills. The 4 day 'NIGRAAN' training package to be offered at the beginning of 7-8 month of the study. These would be full working day workshops conducted in two to three separate sessions as per the design of the training. The refresher training to last for 2 days at the beginning of 13-14 month of the study. The training would be provided by an 'Expert Training Consultant' hired by the project in this regard. The person specifications would include a qualified paediatrician with public health exposure and familiarity with training community based peripheral health workers. The modified supervisory checklist has been adapted from the existing tools available to the LHSs through Pakistan's Lady Health Worker Programme but they are not widely used in practice. It adds certain components (Strengthening Monitoring by LHS of community Case Management Skills of LHW and Direct Observation) and has been organized for the better comprehension. The tally sheet is the consolidated version of the modified supervisory checklist providing at a glance view of the progress and quality of case management as well as picks up the gaps in case management practices of LHWs working under a given LHS. LHSs feedback card is study specific innovation to introduce the practice of written feedback to be provided to LHWs through LHSs.
Sponsors
The Aga Khan University, Karachi
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Educational / counselling / training
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
0 to No maximum
Healthy volunteers
Yes
Inclusion criteria
Lady Health Supervisor (LHS): 1. LHS who is performing duties as part of National Program of Family Planning and Primary Health care within geographical boundaries of District Badin 2. LHS whose employments terms are permanent 3. LHS who conduct ‘field monitoring visits’ and report them to the district level authorities. 4. LHS supervising the LHWs whose catchment area is accessible for the purpose of ‘field monitoring visits’. Lady Health Worker(LHW): 1. LHW who is performing duties as part of National Programme of Family Planning and Primary Health care within geographical boundaries of District Badin 2. LHW who provides services to the households per LHW programme objectives, collect, collate and report the relevant data to the respective supervisor/LHS. 3. LHW whose catchment area is accessible by her LHS for the purpose of ‘Filed Monitoring Visits’. At Community Level: 1. Community caregiver/parent/guardian permanently residing in the household falling under the geographical scope/coverage area of the LHW enrolled into the study 2. Community caregiver residing in a household that has at least one child less than five years of age
Exclusion criteria
Lady Health Supervisor (LHS): 1. LHS who is employed on ‘ad hoc’ or ‘temporary’ basis 2. LHS who assumes the additional responsibilities of higher management level for e.g., Additional District Controller 3. LHS not conducting ‘field monitoring visits’ on a regular basis and also not reporting the progress of the LHWs working under her supervision to the next level of LHW programme authority Lady Health Worker (LHW): 1. LHW not providing services; collecting, collating and reporting the data relevant to the households under her coverage area per LHW programme objectives 2. LHW whose catchment area is not accessible by her LHS At Community Level: 1. Community caregiver who is not the permanent resident of District Badin 2. Community caregiver having a household with no child less than five years of age
Outcome results
None listed