Table 1 Description of the intervention

Rationale/goals

The intervention was designed to target a recognized gap in TB care provided by LHWs by targeting two common barriers to adherence, patient disease understanding, and patient-provider relationship through improved LHW TB knowledge and skills in patient education and adherence counseling.

Materials

The educational outreach component utilized a combination of didactic and interactive techniques including case-based discussions and role playing to efficiently convey TB-specific knowledge and adherence counseling skills and to allow for practice with the point-of-care tool and exchange of ideas between LHWs. Topics included: TB transmission, natural history, treatment, and consequences of poor adherence; the interaction of TB and HIV; and common barriers to adherence and approaches to preventing and addressing non-adherence while maintaining a positive patient-provider relationship.

The point-of-care tool is designed as a laminated chart that can be folded and carried during field visits or stand on the desk to be referenced during patient interactions. One side of the tool provides a visual reminder designed to trigger an adherence discussion during patient encounters and provides clinical support for management of side effects and a constructive approach to addressing issues with adherence. The opposite side uses simple pictorials to illustrate key messages used in patient education and adherence counseling. The tool was pilot tested with LHWs providing TB care at the district hospital.

Both the training manual and point-of-care tool are available at Development and Evaluation of a Tailored Knowledge Translation Intervention to Improve Lay Health Workers Ability to Effectively Support TB Treatment Adherence in Malawi. http://hdl.handle.net/1807/35187

Procedures

Peer-led educational outreach sessions occurred on-site at participants’ base health center during regular work hours. Peer trainers provided a minimum of six sessions, each 60–90 minutes in duration, over a 3-month period.

Intervention provider

TB focus LHWs, general LHWs with 2 weeks additional TB training who are responsible for TB care at the health center level, trained as peer trainers.

Method of delivery

Face to face

Location/context

Sessions took place at the LHWs base health center during regular work hours.

Intensity

6 sessions, each lasting 60–90 min, over a 3-month period.

Tailoring

Additional sessions as makeups for staff that missed sessions, for extra practice as requested of the peer-trainer by the local TB team, or to discuss difficult cases/share experiences within the LHW TB team, were left to the discretion of the peer trainers.

All sites reported meeting at least quarterly to discuss cases, and many reported making up sessions for staff that missed sessions due to illness or leave.

Modifications

Training period extended from 2 to 3 months to accommodate staff absences due to annual leave/illness.

Fidelity

As this was a pragmatic trial, fidelity was not formally assessed due to concerns such assessment could act as boosters to the intervention, which would not occur under real world conditions if scaled up.

Informal reports from peer trainers and LHW participants during quarterly meetings, field visits, and interviews in a companion qualitative study indicated a small number of participants (estimated at 4–5) did not complete the full curriculum.