Intervention |
Aim(s) | Address an identified gap in the training and supervision needs of LHWs providing TB care in Malawi, with the goal of improving TB care and adherence support, and through this improve patient outcomes including TB treatment success rates.
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Content | Training content focused on understanding TB disease transmission and treatment, as well as, common reasons for non-adherence, and approaches to patient education and counselling to support treatment adherence.
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Goal | |
Implementation strategy |
Educational outreach | Peer-led educational outreach provided by TB focus LHWs trained as peer trainers (PT). TB focus LHWs receive two additional weeks of TB specific training and are responsible for provision of outpatient TB care at the health centre level. PTs trained in both content and approach to training and supportive supervision off-site over 1 week by a master trainer (LMPR). Expenses related to travel, accommodation, and meals to attend training reimbursed; training stipends not provided. PTs asked to provide eight cascade training sessions each a minimum of 60 min over a 4-month period, onsite at their base health centre during regular work hours. Training period later extended by 2–3 weeks due to delays in receipt of training manuals at some sites, as well as, PT and/or LHW absences due to annual leave and attendance at off-site meetings or trainings. Organisation and timing of cascade training was left to the discretion of PTs. PTs at liberty to provide additional sessions as needed for LHWs who missed sessions or to train new staff. All LHWs routinely involved in provision of TB care were invited but not required to participate in training. Training stipends were not provided. Methods of supportive supervision discussed and practiced during PT training but approach used left to the discretion of the PTs. Certificates were provided for PTs and LHWs who completed training.
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Clinical support tool | Clinical support tool provided in Chichewa, designed as a laminated flip chart, able to stand on the desk top during patient encounters or to fold flat when carried out to the field. The patient side of the tool uses simple pictorials to outline the course of a patient through treatment, designed as an aid to patient counselling. The provider side of the tool is designed as a clinical support, and outlines an approach to assessing adherence and challenges encountered during treatment, as well as, approaches addressing challenges and to providing counselling and support. An additional leaf on the provider side of the tool provides a drug dosing chart for standard treatment regimens, for easy reference during patient encounters.
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Peer support network | Small telephone stipends were provided quarterly to PTs to support development of a peer support network among PTs trained together. No guidance or encouragement was provided beyond the phone stipend, with participation in and process of peer-support left to the discretion of the PTs.
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PT support/mentorship | PT free to contact the study team by phone with questions or concerns as needed. In order to evaluate the intervention as close to real world conditions as possible, outside support from study team generally limited to quarterly PT meetings and occasional field visits from the study team while collecting process evaluation data and/or during routine site visits from Dignitas International mentors providing support and mentorship to frontline clinical staff in the study districts. Dignitas mentor support withdrawn from two of the four study districts at the end of cascade training as a result of restructuring of NGO catchment areas.
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