Linking informal providers to the formal urban health system for improved access to quality and equitable health services in urban slums in Nigeria

ISRCTN	ISRCTN58193948
DOI	https://doi.org/10.1186/ISRCTN58193948
Sponsor	Foreign, Commonwealth & Development Office
Funder	Foreign, Commonwealth and Development Office

Submission date: 27/01/2026
Registration date: 27/01/2026
Last edited: 27/01/2026

Recruitment status: No longer recruiting
Overall study status: Completed
Condition category: Other

Prospectively registered

Protocol

Statistical analysis plan

Results

Individual participant data

Record updated in last year

Plain English summary of protocol

Not provided at time of registration

Contact information

Prof Obinna Onwujekwe
Principal investigator

Health Policy Research Group, University of Nigeria
4 Hospital Road, University of Nigeria Teaching Hospital, Old Site
Enugu
400001
Nigeria

ORCID ID	0000-0002-1214-4285
Phone	+234 (0)8037007771
Email	hprg@unn.edu.ng

Prof Chinyere Mbachu
Scientific

Health Policy Research Group, University of Nigeria
4 Hospital Road, University of Nigeria Teaching Hospital, Old Site
Enugu
400001
Nigeria

ORCID ID	0000-0003-3936-6184
Phone	+234 (0)8033401942
Email	chinyere.mbachu@unn.edu.ng

Ms Iheomimichineke Ojiakor
Public

Health Policy Research Group, University of Nigeria
4 Hospital Road, University of Nigeria Teaching Hospital, Old Site
Enugu
400001
Nigeria

Phone	+234 (0)8037561460
Email	iheomimichineke@gmail.com

Study information

Primary study design	Interventional
Allocation	Non-randomized controlled trial
Masking	Open (masking not used)
Control	Historical
Assignment	Parallel
Purpose	Health services research
Scientific title	Developing and institutionalising health system linkages between the formal and informal sectors for improving the equitable provision and use of appropriate essential health services in urban slums in Nigeria
Study acronym	CHORUS - Nigeria
Study objectives	1. To examine intervention effectiveness across three critical domains of service delivery in urban slum contexts, i) appropriate management of common illnesses and health conditions by IHPs, ii) referral practices and feedback mechanisms between IHPs and formal providers, and iii) patterns of utilisation of IHP services among community members 2. To evaluate the implementation fidelity and processes of the multicomponent intervention 3. To evaluate the cost and cost-effectiveness of the multicomponent intervention
Ethics approval(s)	Approved 19/01/2024, Health Research Ethics Committee, University of Nigeria Teaching Hospital (Ituku-Ozalla, Enugu, 400001, Nigeria; +234 (0)42-252022, 252573, 252172, 252134; info@unth.edu.ng), ref: NHREC/05/01/2008B-FWA00002458-1RB00002323
Health condition(s) or problem(s) studied	Access to health services
Intervention	The intervention was implemented from July 2024 to May 2025, targeting four key areas, essential to the successful integration of informal providers: 1) improving governance, oversight & management; 2) improving human resource for health capacity; 3) improving service delivery quality and appropriate referrals; 4) improving the quantity and quality of health data reporting from informal providers (health information system); and 5) strengthening community governance and accountability mechanism. The governance intervention involved the creation of a new urban health unit and strengthening the capacity of desk officers of the unit (through training, equipping with necessary tools and monthly supportive supervision visits/technical guidance) to provide oversight and management of informal providers. The human resource for health intervention involved training PHC workers, patent medicine vendors (PMV), traditional birth attendants (TBA) and bonesetters on the recognition and appropriate management of common communicable and non-communicable diseases. The service delivery intervention involved the provision of job aides and six cycles of supportive supervision of the trained providers, introduction of a referral system with referral slips for informal providers. The HMIS intervention involved introducing a daily health record-keeping system for informal providers as part of service delivery and introducing monthly collation of health data of informal providers by PHCs using the monthly summary form. The community participation component involved training and equipping community leaders to provide oversight and support to trained formal and informal providers in the linkage intervention. Process and impact evaluation of the intervention was guided by the RE-AIM framework, which offers a comprehensive structure for assessing public health interventions beyond efficacy alone. RE-AIM was particularly suited to evaluating the extent to which the intervention achieved broad reach among informal providers (Reach), improved service quality and data reporting (Effectiveness), was adopted and implemented as intended (Adoption & Implementation), and showed potential for sustainability (Maintenance).
Intervention type	Mixed
Primary outcome measure(s)	Appropriate management/care for tracer essential health conditions measured using provider survey questionnaire with vignettes, and in-depth interviews of formal providers and focus group discussions with informal providers, at baseline and endline
Key secondary outcome measure(s)	Utilisation of services of trained informal and formal providers measured using household survey at baseline and endline Fidelity/adherence to service quality, referrals and data reporting measured using supervision checklists, in-depth interviews of formal providers and community leaders, and focus group discussions with informal providers and community members at monthly during supportive supervision visits and at endline Cost-effectiveness of the multicomponent intervention measured using desk review of financial reports using costing template to extract cost data at during implementation Provider acceptability of the multicomponent intervention measured using provider survey questionnaire at endline Sustainability and institutionalisation of multicomponent intervention measured using key informant interviews of policy and decision makers, in-depth interviews of formal providers and community leaders, and focus group discussions with informal providers and community members at endline
Completion date	30/06/2025

Eligibility

Participant type(s)
Age group	Mixed
Lower age limit	18 Years
Upper age limit	80 Years
Sex	All
Target sample size at registration	1280
Total final enrolment	1375
Key inclusion criteria	1. Informal health providers (IHPs) in urban slums - traditional birth attendants, bonesetters and patent medicine vendors 2. Formal providers in public primary healthcare centers in urban slums 3. Household heads and primary caregivers in the household who are aged 18 years and above
Key exclusion criteria	1. Minors 2. Adult visitors to households 3. Households or individuals who did not provide consent
Date of first enrolment	07/08/2024
Date of final enrolment	17/09/2024

Locations

Countries of recruitment

Nigeria

Study participating centres

Results and Publications

Individual participant data (IPD) Intention to share	No
IPD sharing plan summary	Not expected to be made available
IPD sharing plan

Editorial Notes

27/01/2026: Study's existence confirmed by the Health Research Ethics Committee, University of Nigeria Teaching Hospital.