Introduction
Drug resistant tuberculosis (DR TB) patient support models of care were designed and piloted by MSF OCB Khayelitsha project in response to the need for a structured approach to the treatment literacy and counseling offered to patients diagnosed with DR TB.
This training module should be read and used by trainers to design DR TB patient support trainings for the appropriate clinic staff in their setting. The module provides trainers with the tools to train clinic teams on the components of the DR TB patient support model. Ideally training should be offered to all members of the clinic team that will be involved with DR TB patients.
Please note: For this training module to be used optimally, the identified trainer(s) must be a skilled in group facilitation and clinical mentorship. Trainers that have less experience in clinical mentorship may benefit from initially reading the Clinical Mentorship Toolkit.
Stepwise guide to training and implementing a DR TB patient support programme
Step 1: Read the DR TB Counseling Toolkit to familiarize yourself with the programme.
Step 2: Select the clinics or facilities in which you would like to implement the DR TB counseling programme.
Step 3: Select the Clinic Teams for your DR TB counseling programme
A Clinic Team = group of individuals you need to successfully implement a programme at clinic level.
Now that you have an overview of the programme from reading the toolkit, ask yourself one question - which staff in my chosen clinic need to be trained on this programme in order to get it going?
To help with answering this question, the DR TB Counseling programme can be broken down into 5 components containing 7 counseling sessions. Counselors need to the trained on how to complete each of these sessions and systems need to be in place to ensure patients experience the appropriate components of the programme.
The 5 components of the DR TB Counseling Programme are:
- 3 initial counseling sessions – completed ideally within the 1st month of DR TB treatment initiation for all patients
- A 4th counseling session – completed at the start of the continuation phase of DR TB treatment for all patients
- Treatment Interrupter session – for patients that have interrupted DR TB treatment for 2 consecutive weeks or longer or have had short frequent interruptions.
- XDR treatment session – for patients with pre XDR or XDR TB diagnosis
- Palliative Care session – for patient in whom DR TB treatment has failed
Sample DR TB Counseling Clinic Team:
1 Counselor – To complete the initial 4 counseling sessions for all DR TB patients, trace treatment interrupters and complete additional counseling sessions as required.
1 Nurse and/or 1 Doctor – responsible for checking TB results, diagnosing DR TB, initiating DR TB treatment and diagnosing treatment failure
1 Counseling Programme Supervisor – To ensure that the counselors are aware of all the DR TB patients and complete sessions as required. This person also completes a monthly report on the programme outcome and completes assessments on each counselor.
Your clinic may need more or less members in its DR TB Counseling Clinic Team. The above is just an example. In your setting it may be the case that only one or 2 staff members are available to share the different tasks. For example, a nurse in your clinic could take on the roles of Nurse and DR Counseling Programme Supervisor at the same time.
Step 4: Plan the training required for Clinic Teams
Double click on icon below to access a sample training timetable. This training timetable is a guide and can be adapted to your particular needs and context. The training we have designed (as shown on the timetable) lasts for 5 days in total. You don’t have to complete all 5 days at once. You can choose to run the training all in one week or split it between different weeks and have separate trainings for the different Clinic Team members. We recommend that you train the individuals from each Clinic Team together though as they benefit from discussing the potential challenges to implementation in their clinic as a group.
Once your training timetable is developed, review the DR TB Counseling Training Facilitator’s Guide. Here you will find step by step guidance on how to complete each part of the training (as detailed in the Training Timetable above). In the Facilitator’s Guide tools needed to complete the training (e.g. power point presentations and practical session plans) are linked to each section.
Step 5: Facility Manager buy-in
It’s crucial to have your facility manager on board before you start training the staff. The facility manager needs to agree to release the clinic staff for the training. Ideally a plan for facility level supervision/support of the programme also needs to be in place before the training goes ahead. For best results, encourage the facility manager to attend at least day 1 of your planned training in order to get a clearer idea of what the programme entails.
Create a brief (ideally one page) outline of the programme and the training you propose. Double click on icon below to view a sample outline document for the DR TB Counseling Programme.
Step 6: Schedule a training
Decide on best dates in co-ordination with the facility manager(s).
Invite Clinic Teams
Confirm attendance 1 week prior
Prepare training packs - double click on icon below for sample training pack.
Step 7: Implementation phase - post training follow up
One of the most important parts of the training is the implementation phase. On-the-job coaching and mentorship will help you ensure the successful implementation and maintenance of your DR TB patient support programme.
Following the classroom training, it is best to schedule follow up on the job coaching and mentorship.
At the beginning of the implementation phase, it is best to have modeling of sessions by experienced staff while the trainee observes. Step by step, these joint sessions should leave the opportunity for the trainees to intervene and participate in the session. Once the trainees feel comfortable, they will facilitate the session by themselves while being supervised by the trainer. Trainers should give constructive feedbacks after each session to empower trainees. Below, you will find a competency assessment tool for the counselors in their DR TB counseling role. This supervision/competency assessment tool can be adapted to suit your context.
Competency Assessment for DR TB Counselling Session 1/ 2/ 3/4/XDR Session/ Palliative Care Session
During this period of follow-up coaching and assessment, it is important for trainers to keep their expectations of the trainees clear through regular (ideally weekly) communication with the trainees and facility mangers. Just as this DR TB Patient support model will have to adapt to suit different settings, trainers may also need to adapt their follow-up and assessment plan in response to the challenges experienced at each clinic. The number of post implementation follow-up sessions required can vary greatly dependent on the challenges that arise with each setting. It is advisable that trainers indicate at the start of this phase, the likely length of their input based on discussions had with the clinic teams during the training week.
The goal of this phase is to support clinic teams to a place where they have an independently functioning and sustainable DR TB patient support programme. Establishing multi-disciplinary team (MDT) meetings which include trainers, trainees and facility (and/or other appropriate) mangers will be greatly beneficial as it creates a platform to discuss and address the challenges as they arise. Continuation of these MDT’s by the clinic team, after the trainers have left, will go a long way to ensuring a sustained programme.