Co-designing and optimising a primary care implementation model for childhood pneumonia management in a low-resource setting using principles of implementation research

Abstract Background Pneumonia remains the leading infectious cause of under-five mortality, particularly in low- and middle-income countries (LMICs) where translation of evidence-based guidelines into practice faces systemic barriers. Although India launched the Childhood Pneumonia Management Guidelines (CPMG), effective implementation remains suboptimal. This study demonstrates how implementation research can support the systematic development and optimisation of a primary care–focused implementation model for childhood pneumonia management in a low-resource setting. This paper reports Phase II of a three-phase implementation research project; Phase I findings are reported in companion publications and Phase III will be reported separately. Methods Phase II of the implementation research project (September 2023–May 2024) employed a mixed-methods iterative design to co-design context-specific implementation strategies using the CFIR-ERIC (Consolidated Framework for Implementation Research- Expert Recommendations for Implementing Change) Barrier Busting Tool and iteratively refine an implementation model through participatory co-design workshops with government and community stakeholders within a learning cluster of approximately 50,000 inhabitants in Palwal district, Haryana, India. An optimised Implementation Research Logic Model (IRLM) was developed to align determinants, strategies, mechanisms of change, and implementation outcomes. Results Thirty-three tailored implementation strategies were identified, addressing barriers across inner (e.g. implementation climate), outer (e.g., socio-cultural norms), individual (e.g. skills), process (e.g., planning), and innovation (e.g., complexity) CFIR domains. Iterative refinement through three successive models (Model 0+, Model 1, and Model 2) within the learning block was associated with improvements in key outcomes: care-seeking from appropriate primary care facilities increased from 0.8% at baseline to over 76% [193/254 cases], appropriate diagnosis improved from 0% to 92.7% [179/193 cases], and fidelity to guideline-based management reached 86% [154/179 cases] by the end of Phase II. These improvements informed the finalised IRLM which was subsequently implemented and evaluated in Phase III. Conclusions This study demonstrates a systematic, transparent, and participatory approach to developing and optimising an implementation model for primary care-based childhood pneumonia management in a resource-constrained setting. The co-designed IRLM, grounded in established implementation research frameworks, offers a replicable process for translating evidence-based guidelines into primary care practice in similar LMIC settings. Phase III along with the district-wide implementation and evaluation findings will be reported in a forthcoming paper. Trial registration Clinical trial registry CTRI/2021/03/031622 [date: 01/03/2021].