Promoting Interventions for Climate Change to Upscale Resilience (PICCTURE) Trial in District Astore

District Astore, located in the mountainous region of Gilgit-Baltistan, is highly vulnerable to climate-related risks, including glacial lake outburst floods (GLOFs), landslides, extreme weather events, and rising temperatures. Its rugged terrain, geographic isolation, dependence on climate-sensitive livelihoods, and limited infrastructure exacerbate the impact of environmental shocks on health and socioeconomic conditions. These vulnerabilities make Astore an appropriate setting to evaluate scalable interventions aimed at strengthening community resilience.

This study is a three-arm cluster randomized controlled trial conducted, where cluster is a village or group of villages. From total available clusters, 30 clusters will be randomly selected and allocated equally across three study arms. Within each cluster, households will be selected through simple random sampling following a complete household listing.

Two intervention arms and one control arm are included. The first intervention arm delivers structured, community-led adaptation and resilience activities through Village Management Committees (VMCs), formed with representation from local stakeholders including elders, teachers, and vulnerable households. The second intervention arm builds upon this approach by incorporating formal engagement of Lady Health Workers and primary healthcare providers to strengthen health-related components, improve service linkage, and enhance outreach to high-risk populations. The control arm does not receive additional inputs.

Intervention components, informed by prior vulnerability assessments, include training and capacity-building on disaster preparedness and response, livelihood diversification, financial literacy, and health awareness. These are delivered through participatory group sessions, simulation exercises, and community mobilization activities over a one-year period. Training sessions are conducted monthly during the initial six months and bi-monthly thereafter, using standardized curricula adapted to the local context.

Primary outcomes are changes in the Disaster Resilience Index (DRI) and Multidimensional Livelihood Vulnerability Index (MLVI), assessed at baseline and endline. Secondary outcomes include health care-seeking, morbidity and mortality, nutrition, environmental resilience, and mental health. Process indicators evaluate intervention delivery, participation, and preparedness mechanisms such as emergency planning, financial coping strategies, and household disaster preparedness. A rapid assessment will be conducted if a major climate-related hazard occurs during the study period to estimate real-world impact under disaster conditions.