Integrated Community Based Health Systems Strengthening in Northern Togo (ICBHSS-Togo)

Integrated Community Based Health Systems Strengthening in Northern Togo: A Stepped-Wedge Randomized Cluster Pragmatic Control Trial

The general objective of this study is to optimize implementation and assess effectiveness of the integrated facility and community-based health systems strengthening (ICBHSS) model in four Northern Togo districts, using the RE-AIM implementation science framework. Specific study aims include: (1) Analyze longitudinal changes regarding maternal and child health outcomes, health service utilization rates, and public sector facility readiness in the ICBHSS model intervention sites catchment areas; (2) Identify barriers to and facilitators of access and quality services related to ICBHSS model; and (3) Assess changes in health care services coverage, effectiveness, and adoption of ICBHSS model. These findings are expected to contribute to continuous quality improvement initiatives, optimize implementation factors, provide generalizable knowledge regarding health service delivery, and accelerate health systems improvements in Togo and more broadly.

Study Overview

• Status: Unknown
• Conditions: Maternal and Child Health; Health Service Utilization
• Intervention / Treatment: Other: ICBHSS model

Detailed Description

Background: Over the past decade the burden of poor maternal and child health outcomes in Togo, particularly in the Northern regions, have remained high despite global progress. The principal causes of under-5 deaths in Togo are diseases with effective and low-cost prevention and or treatment strategies, including malaria (18%), acute lower respiratory infections (15%), and diarrheal diseases (8%).While Togo has an official plan for the integrated management of childhood illness (IMCI), including a permissive policy on integrated community case management (iCCM), challenges in implementation persist with low public sector health service utilization.There are critical gaps in access and quality of community health systems throughout the country and an urgent need to improve health outcomes through expanding access and quality of services.

Intervention: The investigators have adapted an integrated facility and community-based health systems strengthening (ICBHSS) model to improve primary healthcare services in Togo. The ICBHSS model includes a bundle of evidence based interventions including (1) community engagement meetings and feedback; (2) the elimination of facility user fees for children under five and pregnant women; (3) pro-active community based IMCI using Community Health Workers (CHWs) with additional services including linkage to family planning and counseling, HIV testing & referrals; (4) clinical mentoring and enhanced supervision at public sector facilities; and (5) improved supply chain management and facility structures. In 2015, a pilot ICBHSS initiative was launched in partnership with the Ministry of Health (MOH) at four public sector clinics in Northern Togo. Preliminary results from this pilot intervention suggested a meaningful reduction in children under-5 deaths, with a trend in reduction for under-one deaths as well as increased health service utilization at all 4 sites. In collaboration with MOH and technical partners, IH developed a plan to expand the ICBHSS model to 21 distinct health facilities over a four-year period in four additional districts: Bassar, Binah, Dankpen, and Kéran. The planned roll out includes expanding into a new district every 12 months based on budgetary and feasibility considerations. As part of this expansion planned for 2018, Integrate Health (IH) and MOH partners are planning an implementation study to both improve service delivery at expansion sites and inform national scale strategies.

Study: The investigators will conduct a mixed methods assessment, using the RE-AIM framework to evaluate the impact and implementation of the ICBHSS initiative in 4 districts. Consists of three key components: (1) a stepped-wedge randomized cluster pragmatic control trial to obtain annual coverage, effectiveness, and adoption metrics using a population-based household survey, (2) health facility assessments to be completed at the cluster (district) level for each health facility prior to intervention launch and post-intervention, and (3) key informant interviews conducted at 12, 24, 48 months for each cluster. The primary outcome will be under 5 year old mortality rate, with secondary outcomes including under-one mortality rate, maternal mortality rate, as well as maternal and child health service utilization.

• Study Type: Observational
• Enrollment (Anticipated): 7600

Contacts and Locations

• Study Contact: Name: Kevin P Fiori, MD, MPH, MSc; Email: kfiori@integratehealth.org

Study Locations

• Togo
  • Kara, Togo
    • Recruiting
    • Integrate Health

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 15 years to 49 years (ADULT, CHILD)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: Female

• Sampling Method: Probability Sample

Study Population

Females of reproductive age (aged 15-49 years) who reside in a selected household within the study catchment area.

Description

Inclusion Criteria:

• Female of reproductive age (aged 15-49 years)
• Individuals aged 15-17 years will only be included if they have children and/or are pregnant
• Lives in selected household within study catchment area
• Informed consent is obtained for participants 18-49
• Waiver of parental permission is obtained for 15-17 year-old participants

Exclusion Criteria:

• None

Study Plan

How is the study designed?

Number of groups / cohorts

4

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Five facilities in Bassar District; Estimated population of 34,676 served by five public sector facilities in Bassar District.	Other: ICBHSS model; Bundle of evidence-based interventions that include the following 5 components: Community engagement meetings and feedback;; Elimination of public sector facility user fees for children under five and pregnant women;; Pro-active community based IMCI using trained, equipped, supervised, and salaried Community Health Workers (CHWs) with additional services including linkage to family planning and counseling, HIV testing & referrals;; Clinical mentoring and enhanced supervision by a trained peer coach at public sector facilities;; Basic infrastructure improvements and supply chain management training of pharmacy managers
Seven facilities in Binah District; Estimated population of 31,027 served by seven public sector facilities in Binah District.	Other: ICBHSS model; Bundle of evidence-based interventions that include the following 5 components: Community engagement meetings and feedback;; Elimination of public sector facility user fees for children under five and pregnant women;; Pro-active community based IMCI using trained, equipped, supervised, and salaried Community Health Workers (CHWs) with additional services including linkage to family planning and counseling, HIV testing & referrals;; Clinical mentoring and enhanced supervision by a trained peer coach at public sector facilities;; Basic infrastructure improvements and supply chain management training of pharmacy managers
Four facilities in Dankpen District; Estimated total population of 40,165 served by four public sector facilities in Dankpen District.	Other: ICBHSS model; Bundle of evidence-based interventions that include the following 5 components: Community engagement meetings and feedback;; Elimination of public sector facility user fees for children under five and pregnant women;; Pro-active community based IMCI using trained, equipped, supervised, and salaried Community Health Workers (CHWs) with additional services including linkage to family planning and counseling, HIV testing & referrals;; Clinical mentoring and enhanced supervision by a trained peer coach at public sector facilities;; Basic infrastructure improvements and supply chain management training of pharmacy managers
Five facilities in Kéran District; Estimated total population of 31,866 served by five public sector facilities in Kéran District.	Other: ICBHSS model; Bundle of evidence-based interventions that include the following 5 components: Community engagement meetings and feedback;; Elimination of public sector facility user fees for children under five and pregnant women;; Pro-active community based IMCI using trained, equipped, supervised, and salaried Community Health Workers (CHWs) with additional services including linkage to family planning and counseling, HIV testing & referrals;; Clinical mentoring and enhanced supervision by a trained peer coach at public sector facilities;; Basic infrastructure improvements and supply chain management training of pharmacy managers

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Under-five year old mortality rate	The under-five mortality rate (expressed as a rate per 1,000 live births) is the probability of a child dying in a specified year between birth and 5 years of age.	48 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Under-one year old mortality rate	The under-one mortality rate (expressed as a rate per 1,000 live births) is the probability of a child dying in a specified year between birth and 1 year of age.	48 months
Maternal mortality rate	The maternal mortality rate (expressed as a rate per 100,000 live births) is the probability of a mother dying in a specified year within 42 days of pregnancy termination .	48 months
Proportion of children under age five reported to be febrile in the prior two weeks who received an effective antimalarial treatment within 24 hours of symptom onset.	The number of febrile children under-five who received an effective antimalarial treatment within 24 hours of symptom onset out of the total number of children under age five reported to be febrile in the prior two weeks.	48 months
Proportion of children under age five reported to have a cough in the prior two weeks who received an effective pneumonia treatment within 24 hours of symptom onset.	The number of children under-five who received an effective pneumonia treatment within 24 hours of symptom onset out of the total number of children under age five reported to have a cough in the prior two weeks.	48 months
Proportion of children under age five reported to have diarrhea in the prior two weeks who received an effective treatment for diarrheal disease within 24 hours of symptom onset.	The number of children under-five who received an effective treatment for diarrheal disease within 24 hours of symptom onset out of the total number of children under age five reported to have diarrhea in the prior two weeks.	48 months
Maternal facility based birth delivery incidence rate	The proportion of women reported to have delivered in a health facility.	48 months
Protocol Adherence by IH community health workers in iCCM and maternal consultations	The average adherence by IH community health workers to evidence based protocols for iCCM and maternal consultations.	48 months
Protocol adherence by clinical staff at IH intervention facilities in iCCM and maternal consultations	The average adherence by public sector clinical staff at IH intervention sites to evidence based protocols for iCCM and maternal consultations.	48 months

Collaborators and Investigators

• Sponsor: Integrate Health
• Collaborators: Albert Einstein College of Medicine; Montefiore Medical Center; City University of New York, School of Public Health; Ministère de la Santé et de l'Hygiène Publique, Togo; Université de Lomé, Faculté des Sciences de la Santé, Togo
• Investigators: Principal Investigator: Kevin P Fiori, Jr., MD, MPH, Integrate Health; Albert Einstein School of Medicine

Publications and helpful links

General Publications

• Fiori K, Schechter J, Dey M, Braganza S, Rhatigan J, Houndenou S, Gbeleou C, Palerbo E, Tchangani E, Lopez A, Bensen E, Hirschhorn LR. Closing the delivery gaps in pediatric HIV care in Togo, West Africa: using the care delivery value chain framework to direct quality improvement. AIDS Care. 2016 Mar;28 Suppl 2(sup2):29-33. doi: 10.1080/09540121.2016.1176678.
• McCarthy KJ, Braganza S, Fiori K, Gbeleou C, Kpakpo V, Lopez A, Schechter J, Singham Goodwin A, Jones HE. Identifying inequities in maternal and child health through risk stratification to inform health systems strengthening in Northern Togo. PLoS One. 2017 Mar 16;12(3):e0173445. doi: 10.1371/journal.pone.0173445. eCollection 2017.
• Lauria ME, Fiori KP, Jones HE, Gbeleou S, Kenkou K, Agoro S, Agbere AD, Lue KD, Hirschhorn LR. Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol. Implement Sci. 2019 Oct 16;14(1):92. doi: 10.1186/s13012-019-0921-3.

Helpful Links

• Integrate Health

Study record dates

Study Major Dates

• Study Start (ACTUAL): May 1, 2018
• Primary Completion (ANTICIPATED): July 31, 2022
• Study Completion (ANTICIPATED): July 31, 2022

Study Registration Dates

• First Submitted: September 27, 2018
• First Submitted That Met QC Criteria: October 1, 2018
• First Posted (ACTUAL): October 3, 2018

Study Record Updates

• Last Update Posted (ACTUAL): October 15, 2019
• Last Update Submitted That Met QC Criteria: October 11, 2019
• Last Verified: October 1, 2019

More Information

Terms related to this study

• Keywords: Implementation Research; Health Systems Strengthening; Community Health Workers; Child Mortality; Reproductive, Maternal, Newborn, and Child Health
• Other Study ID Numbers: ICBHSS

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No