Implementation research on enhanced community case management of pneumonia in Bangladesh: study protocol

Previous trials in Africa and Asia, including Bangladesh, showed that community health workers can effectively treat young infants (7-59 days) with fast breathing and children (2-59 months) with chest indrawing pneumonia at home with oral amoxicillin using enhanced integrated community case management (iCCM) protocols. However, the Enhanced Management of Pneumonia in Community (EMPIC), its pneumonia-specific component, has not yet been applied in routine government health systems. Here, we developed a protocol for a feasibility study on the integration of EMPIC into community clinics in Bangladesh through existing government health systems.

This study will adopt an implementation research approach that integrates quantitative and qualitative methods. A delivery package will be co-developed with stakeholders to introduce enhanced pneumonia management through government systems in three phases within community clinics of selected upazilas in Kushtia and Dinajpur districts. We will use the plan-do-check-act cycle framework to evaluate implementation, track progress, identify gaps, and test potential solutions. Data collection methods will include health facility assessments, data extractions from routine registers and monthly reports, household surveys, and community follow-ups of under-five children with pneumonia on days 7 and 14 post-treatment. The primary outcome is high (i.e. ≥80%) and effective coverage (i.e. patients receiving the full course of pneumonia treatment) of pneumonia treatment in under-five children. Secondary outcomes include treatment failure rates among under-five children with pneumonia; availability of commodities and supplies for pneumonia management; health worker knowledge, caregiver awareness and care-seeking practices regarding childhood pneumonia; pneumonia prevalence among under-five children; community clinic utilisation for pneumonia-related symptoms by under-five children; and treatment compliance.

Our findings may inform the evidence-based scale-up of enhanced pneumonia management in Bangladesh and other low- and middle-income countries, contributing to improved community-level management of childhood pneumonia.