Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol

BACKGROUND

Over the past decade, prevalence of maternal and child morbidity and mortality in Togo, particularly in the northern regions, has remained high despite global progress. The causes of under-five child mortality in Togo are diseases with effective and low-cost prevention and/or treatment strategies, including malaria, acute lower respiratory infections, and diarrheal diseases. While Togo has a national strategy for implementing the integrated management of childhood illness (IMCI) guidelines, including a policy on integrated community case management (iCCM), challenges in implementation and low public sector health service utilization persist. There are critical gaps to access and quality of community health systems throughout the country. An integrated facility- and community-based initiative, the Integrated Community-Based Health Systems Strengthening (ICBHSS) initiative, seeks to address these gaps while strengthening the public sector health system in northern Togo. This study aims to evaluate the effect and implementation strategy of the ICBHSS initiative over 48 months in the catchment areas of 21 public sector health facilities.

METHODS

The ICBHSS model comprises a bundle of evidence-based interventions targeting children under five, women of reproductive age, and people living with HIV through (1) community engagement and feedback; (2) elimination of point-of-care costs; (3) proactive community-based IMCI using community health workers (CHWs) with additional services including family planning, HIV testing, and referrals; (4) clinical mentoring and enhanced supervision; and (5) improved supply chain management and facility structures. Using a pragmatic type II hybrid effectiveness-implementation study, we will evaluate the ICBHSS initiative with two primary aims: (1) determine effectiveness through changes in under-five mortality rates and (2) assess the implementation strategy through measures of reach, adoption, implementation, and maintenance. We will conduct a mixed-methods assessment using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. This assessment consists of four components: (1) a stepped-wedge cluster randomized control trial using a community-based household survey, (2) annual health facility assessments, (3) key informant interviews, and (4) costing and return-on-investment assessments for each randomized cluster.

DISCUSSION

Our research is expected to contribute to continuous quality improvement initiatives, optimize implementation factors, provide knowledge regarding health service delivery, and accelerate health systems improvements in Togo and more broadly.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03694366 , registered 3 October 2018.

[Comparative study of neonatal bacterial meningitis in Lomé, Bobo-Dioulasso, Casablanca and Lyon]

Bacterial meningitis in new-borns remains a serious event because of its high mortality and morbidity rates in Africa.

OBJECTIVE

To identify the clinical and bacteriological epidemiology and the outcome of neonatal bacterial meningitis in three African cities.

METHOD

We have analysed and compared three hospital studies done in humid tropical, Sahelian, and desert Africa with a European study.

RESULTS

Compared with the European study this African study is characterized by a high mean frequency of neonatal meningitis (6 cases per year against 1.4), more important risk factors linked to pregnancy and childbirth (50% against 33%), high rates of death (61 to 68% against 5%) and sequelae (25 to 40% against 30%), rarity of Streptococcus agalactiae (7 to 15% against 38%) and absence of Listeria. Enterobacteriaceae were predominant both in African (50 to 68%) and European (43%) studies. E. coli appeared as the most frequent germ in both European and African studies and Salmonella as more frequent in Sub-Saharan Africa than in occidental countries.

CONCLUSION

The epidemiological, bacteriological and evolutional aspects of the neonatal meningitis were identical in the three African cities. The African studies were different from the European only by their high incidence, the rarity of S. agalactiae and Listeria and the difficulties of bacterial diagnosis and management, all might explain the high rates of death and sequelae. An epidemiological survey and adequate antimicrobial therapy according to antibiotic susceptibility may improve the outcome.

[Bacterial flora in the genital tract the last trimester of pregnancy]

Very widespread in our clinical setting, early-onset sepsis is due to organisms that commonly colonize or infect the maternal genital tract; identifying such organisms would help improve prevention and treatment.

OBJECTIVE

To determine the bacterial ecology and the pathological status of the genital organs during the last trimester of pregnancy, in order to evaluate the risk of materno-fetal infections and to improve the present prophylactic measures based on monitoring bacterial carriage during the first trimester.

METHOD

Vaginal and endocervical samples, usually taken during the first trimester of pregnancy were delayed and taken during the last trimester of pregnancy, in patients with no signs of sepsis and not taking antibiotics. A macroscopic examination described the aspect of the vagina, the cervix uteri, leukorrhea and possible inflammatory lesions or ulcerations. A microscopic examination searched for parasites, epithelial cells, Clue cells and leukocytes. The appropriate bacteriological cultures were performed after reading the Gram stain and scoring the vaginal flora. The clinical and cytobacteriological aspects were used to identify the bacterial ecology and the pathological genital states.

RESULTS

Genital samples were collected from 306 pregnant women. Among them 118 were at 29-32 weeks of gestation, 104 at 33-36 and 84 at 37-40. The most frequent germs were C. albicans (33.3%), Enterobacteriaceae (20.3%) including E. coli (10.9%), S. aureus (15.4%), Gardnerella (13.6%), and Trichomonas (10.6%), in monomicrobian (79.2%) or polymicrobian carriage (20.8%). Lower genital tract pathological states such as vaginitis (29.4%), bacterial vaginosis (21.5%) or cervicitis (10.4%) and asymptomatic bacterial carriage (23.5%) and normal genital flora (15%) were identified.

CONCLUSION

This is the first report of genital bacterial carriage in African women during the last trimester of pregnancy. Larger studies are required to evaluate the risk of maternofetal infections and to improve current prophylaxis measures.

[Risk factors associated with prematurity at the University Hospital of Lome, Togo]

OBJECTIVE

To determine the premature birth rate and the risk factors of preterm delivery linked to local conditions of life.

METHOD

It is a prospective study including all births before 37 amenorrhoea weeks. All social, medical and behavioural factors linked to preterm deliveries have been analysed for and compared with those of the medical literature.

RESULTS

Out of 1672 alive births, we identified 186 (11.1%) cases of prematurity and 30.1% of lethality. The main risk factors of preterm delivery were history of adverse pregnancy outcome (17.2%), history of induced abortion (11.3%), maternal age under 20 (26.3%), under 20 year old primipara (38.7%), inadequate antenatal care (66.6%), low level of education (38.7%) and mother suffering of overwork (29%). Other associated factors such as premature membrane rupture, malaria, urinary infections, gravidic toxaemia, genital infections and above all "unmarried-under 20 year old-primipara with low level of education and low socio-economical status", were significantly linked to preterm delivery.

CONCLUSION

The risk factors thus identified correspond with the well-known factors. But many factors significantly linked to preterm delivery were local features whose importance could be reduced through better means of perinatal care and prevention.

[Upper arm circumference reference values for children aged 1 to 36 months in Lome (Togo)]

BACKGROUND

Mid-upper-arm circumference (MUAC) is widely used as a nutritional status index for children. The aim of our study was to construct MUAC-for-age curves for well-fed 1-36-month-old children of a developing country and to compare them with the WHO reference charts based on samples of American children.

POPULATION AND METHODS

Five thousand thirty-eight boys and 4,972 girls aged 1-36 months were recruited cross-sectionally from 1994 to 1997. Their MUAC were measured as recommended by the WHO. To develop the curves, estimations were first obtained for the mean and standard deviation (SD) of MUAC for each month of age using a 7-month segmental regression equation; the Count model and 2nd degree polynomial in age were then used to describe the mean and SD respectively.

RESULTS

These curves showed important differences for age and sex and were lower than the reference curves, particularly for the older children. The mean curve was -0.44 to -0.75 SD for boys and 0 to -0.8 SD for girls, far from the WHO's reference.

CONCLUSIONS

The authors proposed to take into account the WHO's nutritional recommendations and developing country features in the construction of the reference charts.

[Neonatal mortality in the Tantigou pediatric hospital, Dapaong (north Togo) in 1984-1985 and 1994-1995]

370 deaths out of 1141 hospitalized cases of newborns aged 0-28 days were retrospectively analyzed in the Tantigou pediatric hospital of Dapaong, situated 645 km from Lome in northern Togo, in 1984-1985 and 1994-1995. A decreasing trend in neonatal mortality was noted: 42.5% and 27.6% respectively. Major causes of death were prematurity or low birth weight, sepsis, hypoxia conditions. The attendance of pregnant women at health information centres seems to be improving, but the neonatal mortality rate remaining high, the implementation of primary health care/Bamako Initiative resulting especially aiming at better prenatal care for pregnant women must be sustained.

[Bourneville's tuberous sclerosis and childhood epilepsy Apropos of 4 cases in Togo]

The authors report four cases of childhood epilepsy symptomatic of tuberous sclerosis. Epilepsy appeared in the forefront of the epileptic scene: in two cases, the features of epilepsy were haut mal and in two cases, WEST'S syndrome. Epileptic seizures began precociously for all children. Mental retardation was identified in three cases with one case of autistic behaviour. Diagnosis was possible given skin lesions, family investigations, and X-ray of the skull. Brain scanners were not carried out on any of the children. Whilst recognizing the scarcity of BOURNEVILLE'S tuberous sclerosis, the authors point out the need for interdisciplinary collaboration in the diagnosis of rare but not exceptional hereditary affections.