Supportive supervision of Lady Health Workers to improve quality of services for addressing childhood pneumonia and diarrhea prevention and treatment - the nigraan plus trial

Brief name: intervention arm Rationale Lady Health Workers (LHWs) have had little impact on increasing coverage of pneumonia and diarrhea treatment interventions. Despite the deployment of over 100,000 LHWs the under-five mortality rate in Pakistan is stagnant. Only 38% children sick with diarrhea receive ORS and a mere 42% with pneumonia receive antibiotics. 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. Therefore identifying 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. Therefore, project “NIGRAAN plus” aims 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. Primary aim is to improve the CCM and supervision skills of LHSs for childhood diarrhea and pneumonia and assess trickle-down effect on improvement in LHW CCM performance and community caregiver practices. Methods and materials: This is a two year cluster randomized controlled trail. The intervention will be rolled out in three phases. A six month pre-intervention phase will be followed by the active intervention phase of 12 months. The study will be conducted in District Mirpur Khas, in Sindh with LHS, LHW, primary caregivers of children under five (mothers), implementers and policy makers as study participants. The study will be implemented in three stages. In the pre-intervention period, formative research will be done to build the optimized supervisory intervention. Focus group discussions (FGDs) and key informant interviews will be conducted with LHWs, LHS, Provincial Coordinator LHW program, District Health Officer, Additional District Commissioner, and decision makers – Secretary/Addl. Secretary Health, and the results will be fed into an evidence-based intervention. Participants will receive a minimal allowance for travel. A sample baseline household survey will be conducted in this phase to study caregiver knowledge and practices about childhood diarrhea and pneumonia. The survey will also assess caregivers’ knowledge, attitudes and perceptions about the LHW program. A baseline assessment of knowledge and skills of all study LHWs and LHSs will also be conducted in the pre-intervention period. In the next phase, the intervention will be rolled out which consists of training intervention LHSs in community case management (CCM) skills as well as supervision skills. The training will utilize lectures, audiovisual aids, and a training manual formulated by the research team building on Lady Health Worker Program (LHWP) diarrhea and pneumonia CCM curriculum. Two project Co-investigators will conduct the training only to intervention arm LHSs. The training will consist of 22 sessions over three days with each session lasting about an hour. The training will consist of three modules. The first module – the introductory module – will refresh LHSs knowledge and skills for CCM of diarrhea and pneumonia. The sessions in this module will deal with clinical management of childhood diarrhea and pneumonia in the community. These skills include history taking, examining the sick child, and recognizing signs that should prompt treatment and/or referral. Additionally, the in-class training will be complemented by supervised hand-on practice of these skills in a hospital. The second module, called introduction to supervision module, will familiarize LHSs with the roles and qualities of a supervisor, expectations from a supervisor, the distinction between supervision and mentoring, and various types of supervision. The third and final module, called giving structures feedback to LHWs, will deepen LHSs understanding of supportive supervision. In this module LHSs will also be trained in providing structured written feedback to LHWs and providing clinical mentoring to LHWs. Finally, supervision tools to be utilized in the study will be introduced and LHSs will be trained in using them. During the intervention phase, intervention arm LHSs will provide written feedback to LHWs about the LHW’s CCM performance in real time in the community. A surveillance system with SMS based communication will be set up to improve communication between LHWs and LHSs so that cases are promptly reported and supervision visits can take place timely. Currently, no such system of communication exists between LHWs and LHSs and an LHW reports all her cases to the LHSs in a monthly report. With Nigraan plus’s SMS based surveillance system, LHWs can promptly report cases to the LHS and the LHS can plan a field supervision visit during the next 24 hours. During that visit the LHS will provide mentoring and supervisory feedback (verbal and written) to the LHW in real time in the field during follow up visit to the sick child’s house. By LHW program requirement an LHS must conduct a supervisory visit with each of her LHWs at least once a month. During the intervention period, periodic knowledge and skill assessments of LHWs and LHSs will be done through structured instruments by trained independent evaluators. At the end of the intervention period, an endline household survey will be done with caregivers. An assessment of LHS and LHW knowledge and skills assessment will be done. A final assessment of LHW and LHS knowledge and skills will be done six months after the end of intervention. The following tools will be introduced to complement the above trainings to address the structural gaps in the existing LHS supervisory tools: i. Modified Supervisory Checklist: this modified checklist removes ambiguities in the original checklist related to monitoring of LHWs through direct observation. ii. LHS Feedback Card for Individual LHWs: This innovation addresses the gap identified in FENP: 61 per cent of LHWs received no feedback from their supervisors by making the feedback process specific and clear. These instruments will be refined and finalized after the pre-intervention formative research. Based on current LHS charter of responsibilities and consultations with the DoH, the additional time required by LHSs to implement these tools is anticipated to be approximately 10 minutes per LHW per month. In the project report we will report on the training sessions as planned. Regarding intervention fidelity, feedback card distribution, will be tracked through monthly monitoring data which will provide data about provision of feedback to LHWs.