Table 1 Description of intervention

Rationale/goals

Goal of the intervention is to improve TB care provided by LHWS and in particular treatment adherence counselling and support to address factors related to incomplete treatment, and through this improve successful treatment rates and patient outcomes.

Materials and procedures

The TB adherence intervention required providers to assess adherence, to provide education and counselling based on risk factors for non-adherence, and to address any patient questions or concerns at each clinical encounter.

Three implementation strategies were employed to support implementation: on-site peer-led educational outreach, point-of-care reminder tool, and peer support network.

Educational outreach employed both didactic and interactive techniques including case-based discussions and role playing to convey TB-specific knowledge and job-specific skills and to allow for practice and sharing of ideas and experiences between LHWs. Topics included TB transmission, treatment, and consequences of poor adherence; the interaction of TB and HIV; common barriers to adherence; patient-provider communication skills including approaches to preventing and addressing non-adherence; and methods and benefits of supportive supervision. Peer trainers were trained both in the content and approach to teaching off-site by a master trainer (LMPR) and provided with a training manual and resources (flip chart, markers, etc.) and received certificates at completion of training. Peer trainers led educational outreach sessions at their base health centre during regular work hours. Peer trainers were asked to provide eight sessions, each a minimum of 60 min in duration, over a 4-month period, and to provide supportive supervision throughout the study period.

Point-of-care tool was designed as an A4 size desktop flip chart that can be folded to be carried for field visits. The patient side of the tool uses simple pictorials to illustrate key messages, for use in patient education and adherence counselling. The provider side of the tool provides a guide to discussing adherence and providing adherence counselling, as well as clinical support for management of side effects. A third page included the basic TB treatment dosing regimens for easy reference during patient encounters. The tool was revised based on feedback from LHW participants in the pilot study and further revised through usability testing with LHWs in the pilot district (not part of the current study) prior to implementation.

Peer support network. A small (approximately one USD) amount of money was provided quarterly for phone credit to facilitate development of a peer-support- network among peer trainers, who were trained together but are generally widely dispersed across large geographical areas. Networking was further supported by quarterly in-person meetings with peer trainers and the study team.

Intervention provider

TB-focus LHWs from each intervention site were trained as peer trainers. TB focus LHWs are general LHWs with varying years of LHW and TB experience, who receive an additional 2 weeks of TB-specific training from the ministry of health and are responsible for outpatient TB care at the health centre level. Note, at least one TB focus LHW had not received their TB focus training at the start of the intervention, but did receive it shortly after they received the intervention training.

Method of delivery

Educational outreach sessions were provided face to face.

Location/context

Sessions took place at the LHWs base health centre during regular work hours, typically afternoons on less busy days of the week (i.e., mid-week).

Dose

Peer trainers were to provide eight sessions, each lasting a minimum of 60 min, over a 4-month period, and to provide supportive supervision throughout the study period.

Tailoring

Additional sessions as make-ups for staff that missed sessions, joined the health centre team outside the initial training period or for LHWs who initially declined to participate but later requested training, were left to the discretion of the peer trainers.

Several suggested approaches to supportive supervision were discussed and practiced during peer trainer training, with the form used left to the discretion of individual peer trainers.

Modifications

Training period extended formally from 2 to 3 weeks depending on the timing of the peer trainer training in the district to accommodate staff absences due to annual leave/illness/TB focus training/national exams and delay in dissemination of training manuals.

In additional to individual make-up sessions as outlined and planned for through tailoring, some peer trainers trained a second cohort later in the course of the study, due to staffing changes and/or to train LHWs who had initially declined to participate in training.

Fidelity