Implementation Research to increase coverage of pneumonia treatment in under-five-year-old children in a North Indian district: Study Protocol

Introduction

The National Family Health Survey-5 has reported an under-five mortality rate of 41.9 per 1000 live births in India. Pneumonia, one of the leading causes of under-five mortality contributes substantially to this figure. The Indian government has made efforts through multiple national programs, but pneumonia-specific mortality remains high. The Government of India revised their Childhood Pneumonia Management Guidelines in 2019 to improve under-five pneumonia prevention and management. This study aims to achieve a high population-based coverage of pneumonia treatment for under five-year-old children in the Palwal district of India.

Method and analysis

This research utilizes a quasi-experimental pre-post design and a mixed-method approach. The study is in Palwal district, which has a population of about 1.3 million and numerous government healthcare facilities. The catchment area focuses on Health and Wellness Centers, which are the most accessible public health facilities for the community, located close to the homes.The intervention focuses on early pneumonia identification by community healthcare workers and referral of these cases, prompt care-seeking by caregivers from appropriate healthcare providers, and appropriate diagnosis, management of cases at out-patient basis by healthcare providers and referral of severe cases to higher facilities.. The research team (RT) will provide technical inputs and guidance to government staff, who will implement the interventions. The RT comprises three teams: the implementation support team, the program learning team, and the outcome measurement team. The study has three phases: I-Formative research, II-Model optimization, and III-Scale-up and concurrent evaluation. Data will be collected using electronic tablets and the REDCap platform. Data analysis will be performed using Stata 16 and NVivo.

Ethics and dissemination

Ethical approval was granted by the ethical committees of the Society for Applied Studies ( SAS/ERC/IR Pneumonia/2021 ) and the World Health Organisation ( WHO/ ERC.0003652 ). This research is registered in the clinical trial registry CTRI/2021/03/031622 . [Registered on: 01/03/2021]. Dissemination meetings in the study country will share results with stakeholders, including Ministry of Health officials, health managers, families of under-five children, community leaders, and academia, to discuss national health program implications. Results will also be shared regionally and globally, with publications and presentations encouraged in national and international forums.

Strengths and limitations of this study

• Provides empirical evidence on implementing a national guideline on childhood pneumonia management in a resource-limited district, highlighting real-world challenges and solutions.

• May demonstrate the potential of community-level health workers and primary care healthcare providers in increasing the coverage of pneumonia treatment among children, emphasizing the importance of localized, context-specific strategies.

• Integration of key outcome indicators into the Health Management Information System (HMIS) may enhance public health data systems and ensure sustainability in management.

• May contribute to the global discourse on under-five pneumonia management in low- and middle-income countries, providing insights that can be adapted to similar settings globally.

• However, Reliance on self-reported data from caretakers may introduce a potential recall bias.

Additionally, a broad operational definition of pneumonia may lead to false-positive cases reported to healthcare facilities.