Building communities of practice through case-based e-learning to prevent and manage TB among people living with HIV–India

doi:10.21203/rs.3.rs-1737597/v1

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Building communities of practice through case-based e-learning to prevent and manage TB among people living with HIV–India

https://doi.org/10.21203/rs.3.rs-1737597/v1

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published 29 Dec, 2022

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Background: Addressing TB among people living with HIV (PLHIV) is a key priority for the Government of India (GoI). In 2016, GoI implemented single-window services to prevent and manage TB in PLHIV. To strengthen HIV-TB service delivery, case-based e-learning was introduced to health care providers at ART centres (ARTc).

Methods: We implemented a hub and spoke model to deliver biweekly, virtual, case-based e-learning at select ARTc (n=115), from four states of India-–Delhi, Uttar Pradesh, Andhra Pradesh and Tamil Nadu. We evaluated feasibility and acceptability of case-based e-learning and its impact on professional satisfaction, self-efficacy, knowledge retention using baseline and completion surveys, session feedback, pre-and post-session assessments. We reviewed routine programmatic data and patient outcomes to assess practices among participating ARTc.

Results: Between May 2018–September 2020, 59 sessions were conducted with mean participation of 55 spokes and 152 participants. For 95% and 88% of sessions≥80% of respondents agreed that topics were clear and relevant to practice, and duration of session was appropriate, respectively. Session participants significantly improved in perceived knowledge, skills and competencies (+8.6%;p=0.025), and technical knowledge (+18.3%;p=0.04) from baseline. Participating ARTc increased TB screening (+4.2%,p<0.0001)), TB diagnosis(+2.7%,p<0.0001), ART initiation(+4.3%,p<0.0001) and TB preventive treatment completion (+5.2%,p<0.0001).

Conclusion: Case-based e-learning is an acceptable and effective modus of capacity building and developing communities of practice to strengthen integrated care. E-learning could address demand for accessible and sustainable continuing professional education to manage complex diseases, particularly co-morbidities and thereby enhance health equity.

case-based e-learning

HIV-TB

ECHO

capacity building

communities of practice

integrated care

With 2.35 million persons living with HIV (PLHIV)1 and 2.59 million incident cases of TB per year2, India has an estimated 53,000 co-infected people and 11,000 estimated deaths in 2020.3 The risk of developing tuberculosis may be 15–22 times greater in PLHIV4, higher rates of mortality, causing one-in-three AIDS-related deaths.5 Globally only 49% of people with HIV-TB were receiving treatment for both conditions6 and co-management of HIV-TB coinfection continues to remains challenge.

To strengthen collaboration between India’s National AIDS Control Programme (NACP) and National TB Elimination Programme (NTEP), GoI launched single-window services for prevention and management of TB in PLHIV through Antiretroviral Therapy centres (ARTc) in December 2016, with an overall aim of providing optimum care to HIV-TB co-infected persons. With the revised guidelines, role of ARTc staff expanded to include TB management (which was hitherto done by NTEP) necessitating continuous capacity building of the ARTc staff on HIV-TB care which was already deficient7. Implementation of integrated service delivery was further compounded by having two vertical national programs for HIV and TB with separate capacity building and program management systems. A unified capacity building initiative was required to strengthen co-management of HIV-TB dual infection.

A case-based learning initiative for mentoring and capacity building using Extension of Community Care Outcomes (ECHO) platform, was designed to build communities of practice for strengthening HIV-TB care at ART centres. Globally, this is the primary/first ever innovation which dealt with two different diseases and trained health care providers on integrated management of HIV-TB through case-based e-learning. The ECHO model has been successfully used in PEPFAR-supported countries to scale up HIV treatment8^,9 and in India for mentoring TB care providers.

In May 2018, NACP rolled out this case-based e-learning initiative to strengthen HIV-TB care at 115 ARTc that provided care to 391,264 PLHIV. Here, we described the feasibility and acceptability of the case-based e-learning for HIV-TB care and its impact on professional satisfaction, self-efficacy (knowledge, skills and competency), technical knowledge retention (short-and long-term) and change in practices among providers for HIV-TB care at ARTc in India.

Study type, population and setting

This descriptive study included a cohort of ARTc staff invited to participate in case-based e-learning. NACP provides care and treatment services to 1.48 million PLHIV through 620 ARTc which are primarily located in the public health institutions and provide single-window services for HIV-TB care10. National Institute of Tuberculosis and Respiratory Diseases (NITRD), moderated sessions as hub and 115 ARTc from four states (Delhi, Uttar Pradesh, Andhra Pradesh and Tamil Nadu) participated as spokes. The subject matter experts on HIV and TB were drawn both from NACP and NTEP, to provide expert opinion and facilitate case discussion.

Sample size

We purposefully selected two states with a high HIV prevalence (> national average of 0.22%) and two states with low HIV prevalence (< national average) to implement the intervention at all ARTc. Participating staff from each ARTc included medical officer, nurse, counsellor, pharmacist and other cadres (data manager, care coordinator and lab technician).

E-learning intervention

This intervention was anchored on the conceptual framework of building communities of practice, defined as “groups of people who share a common concern/problems/passion, and deepen their knowledge and expertise by interacting on an ongoing basis”.11 We developed curriculum based on the national TB prevention and management guidelines for PLHIV, in consultation with experts from both the programs. We ensured availability of a computer, web camera, speaker with microphone, internet connectivity as per guidelines. We provided an orientation to the spokes on case-based learning through a virtual platform and took feedback on preferred session day/timing to facilitate attendance.

The spokes shared difficult-to-manage cases in a standard format that captured clinical and laboratory details and the key queries about the case management. During the one-hour sessions, a predetermined spoke presented the case, followed by case discussion/didactic and proposed recommendations for case management by the invited subject experts.

Data collection and management

Data was collected to understand– i. feasibility and acceptability of the case-based e-learning; ii. impact on professional satisfaction, self-efficacy (knowledge, skills and competency), technical knowledge retention (short-and long-term) and change in practices among providers.

Feasibility and acceptability of e-learning

Feasibility and acceptability was assessed by using in-session information on date/time, participation, topic and expert. Each session concluded with a poll which captured feedback on four variables–quality, clarity, relevance of content, appropriateness of duration; and overall rating of the session which allowed open-ended comments from participating sites. Feedback using a structured questionnaire was collected from experts who facilitated case-discussions.

Impact of e-learning

Impact was analysed using three parameters–self-efficacy (an individual's belief in his or her capabilities to produce specific performance attainments), knowledge retention, and change in practices and patient outcomes. To assess self-efficacy (knowledge, skills and competencies) and long-term technical knowledge retention, each spoke was subjected to baseline and completion (at the end of 18 months) survey via an electronic structured questionnaire. Short-term technical knowledge retention was assessed through pre-and post-session assessment at the end of each session. We reviewed routine programmatic data to assess practices among participating ARTc.

Data Analysis:

To assess feasibility of e-learning, we calculated percentages for categorical variables using in-session data. We categorised sessions into five domains–diagnosis, treatment, prevention, pharmacological aspects and monitoring. Session participation, participant feedback was disaggregated into 5 domains. Responses from participants and experts on session feedback was collected on five-point scale and responses were re-categorised into three groups–Agreed, Neutral and Disagreed. ‘Agreed’ response rate for each session by feedback variable was calculated. A session was classified to have received as positive feedback if the agreed response rate was ≥ 80% for a specific variable (Table-1). We calculated percentage of positive response for each survey question from experts. We compiled all qualitative response from participants and included those pertaining to quality and relevance of the sessions for analysis. Qualitative responses were recorded in text using double quotations as per standards of presenting qualitative data.

To assess impact of e-learning, responses to ten self-efficacy questions through baseline and completion survey were collected on seven-point Likert scale for each question. Responses were re-categorised into three groups–Agreed, Neutral and Disagreed. Perceived mean scores of baseline and completion surveys were calculated and a paired t-test was used to determine the change in the perceived self-efficacy. For calculating the short-term technical knowledge retention, we used t-test to determine the mean difference in pre-and post-test scores administered during each session. For calculating the long-term knowledge retention, paired t-test was used to determine the mean difference in baseline and completion scores before and after 18 months of the intervention. To estimate improvement in practices, we used chi- square test to measure change in process and patient outcomes–TB screening, TB referral, TB diagnosis, ART initiation and TB preventive treatment (TPT) completion rates over time.

Between May 2018–September 2020, 59 e-learning sessions were conducted, spanning across five domains–diagnosis [n = 10(17%)], treatment [n = 27(46%)], prevention [n = 8(14%)], pharmacology [n = 8 (14%)] and monitoring [n = 6 (10%)].

Feasibility of e-learning: The mean number of participating spokes per session was 55 and 100% spokes were retained until the completion of the study period. Each session had an average of 152 participants (range: 95–281) of which 15% were medical officers, 13% nurses, 26% treatment counsellors, 17% pharmacist and 38% were others [data manager, lab technician and care coordinators] (Figure-1). Participation was observed to be highest in sessions related to TB diagnosis (n = 181) and treatment (n = 153) (Figure-2). Logistic issues leading to interruptions of session were reported for 2/59 (3%) sessions and were mainly internet related. For 81% of sessions, ≥ 80% of respondents found the session addressed specific queries they had; for 95% of sessions, ≥ 80% of the respondents agreed that topics were relevant to practice as well as had clarity and ease of understanding and; for 88% of sessions, ≥ 80% agreed that the duration of session was appropriate (Table-1).

Qualitative feedback received from participants during in-session discussions from participants included comments such as: “topic was work related”; “didactic presented in a way, which kept us awake even after lunch”; “information provided in fine sequence”; “sessions provide an opportunity to discuss the complex HIV-TB cases with experts, while sitting at the ARTc”; “we can choose the cases and then discuss them as per our priority”; “sessions provided insight on clinical as well as operational and data management aspects”; “sessions updated us on HIV-TB national guidelines”; “our queries were also solved on the treatment guidelines for paediatrics”; “great medium to learn best practices from other ARTc”; “we are thankful to our ART colleagues for sharing their cases with us”.

Of the 15 experts who responded to the survey, 11(73%) had facilitated 2 or more e-learning sessions. All the experts (100%) agreed that e-learning was an effective modus of capacity building of staff spread across various geographies; the case studies presented by the ARTc were relevant; pre-session information and assistance was adequate; and opined that the e-learning initiative should be scaled up. Whereas 87% responded that internet connectivity was not a challenge; 73% thought participant interaction to be adequate and case presentation by the ARTc of good quality and; 93% agreed that format and time for the session were appropriate and adequate (Figure-3).

Qualitative feedback from the experts included comments such as: “a promising initiative to help field staff across different geographies”; “a good initiative to be scaled”; “it's a pathbreaking in terms of imparting pertinent clinical knowledge”; “helps in building communities of practice” and “overall a good initiative”; “need to expand the scope to non-communicable diseases”.

Impact of e-learning

72/115 (63%) of spokes responded both for the baseline as well as the completion survey for assessment of self-efficacy (knowledge, skills and competencies) and long-term knowledge assessment.

Self-efficacy

Perceived ease of access to experts and perceived ability to share clinical expertise with colleagues from other ARTc increased by 13% and 6% respectively. An increase of 8.6% (p = 0.025) was reported in self-efficacy (perceived knowledge, skills and competencies) on self-assessment, particularly with reference to ability to identify symptoms of TB in PLHIV (9.8%, p = 0.03), ability to diagnose and treat complicated cases of HIV-TB (11.4%, p = 0.05) and ability to assess and manage other co-morbidities in patients with HIV-TB (8.9%,p = 0.02) (Table-2).

Technical knowledge retention: Mean pre-and post-session scores to assess short-term technical knowledge retention indicated 16.2% (CI:13.2–18.9,p < 0.001) improvement in technical knowledge score across the domains. Spokes who responded to both baseline and completion survey on long-term technical knowledge retention (n = 72/115), reflected an overall improvement in correct responses to technical questions by 18.3% (p = 0.04) from baseline.

Practices and patient outcomes: There was an increase in four-symptom screening by 4.2% (CI: 4.1–4.2,p < 0.0001); referrals for TB diagnosis by 2.0%(CI:1.5–2.3,p < 0.0001); TB diagnosis by 2.7% (CI:2.4–3.0,p < 0.0001); ART initiation by 4.3% (CI:3.8–4.8,p < 0.0001), TPT completion by 5.2% (CI:5.0–5.5,p < 0.0001).

To address gaps in HIV-TB co-management, innovative means for service delivery, complemented by continuous capacity building of staff are critical. The study evaluated the feasibility, acceptability, and effectiveness of case-based e-learning for HIV-TB care among providers at ARTc. The findings indicate substantial improvement in knowledge of participating spokes across all curriculum domains and a significant increase in self-efficacy, satisfaction, acquisition of knowledge and new skills. All categories of staff were interested in sessions, substantiating ECHO sessions as an acceptable means of team learning for ART centres’ staff and building communities of practice. Participation of non-clinical healthcare workers suggested increase in ownership and accountability by engaging them in development of session topics and presenting didactic lectures and cases. Participants reported most of the sessions to be clear with appropriate content, suitable timing and seamlessly broadcast without technical issues. The improvement in knowledge was translated into clinical management of TB as indicated by increase in symptom screening, diagnostic referral, TB treatment initiation and TPT completion rates. The flexibility to revise the curriculum based on participant feedback and dynamic changes in the treatment and monitoring protocols is another advantage of the e-learning initiative for relevant content and improved patient outcomes.

Like other ECHO projects our evaluation demonstrated the ability of the HIV-TB e-learning initiative to improve healthcare worker knowledge and satisfaction and decrease professional isolation.12 E-learning pedagogy provided participants an opportunity for active interactions and cross-learnings among peers, thereby building communities of practice as observed in other case-based e-learning initiatives.13^,14 Findings reflect that it is feasible to provide continuous capacity building and mentoring of field staff without travel or suspension of clinical services in a cost-efficient manner as reflected in other similar interventions.15^,16^,17^,18

Experts engaged in this intervention found e-learning as an effective and interactive means for capacity building of staff distributed across remote geographies and suggested expansion to other geographies and disease programs.19^,20

The e-learning initiative facilitated both short-and long-term retention of participant knowledge, which was comparable to other similar interventions,21^,22 though most training methodologies have limitation to evaluate the long-term retention in Indian context.

Limitations

Improvement at individual level count could not be analysed as knowledge survey was by sites. Implementation coincided with COVID surge, leading to competing priorities for health care providers which influenced their participation and therefore impact may have been more than what we were able to measure.

The communities of practice developed through this intervention have decreased provider isolation and increased provider satisfaction, especially in light of current high staff turnover. This initiative garnered combined expertise from TB/HIV programs to seek timely guidance by ARTc staff on complex queries related to prevention and management of HIV-TB. Findings recommend expansion of this initiative across the country to augment the existing capacity building interventions and engage other cadres who could potentially benefit from routine mentorship and continued professional development. Resonating well with lessons learnt during COVID-19 pandemic regarding use of technology, this initiative not only promoted health equity by timely provision of expert opinion to staff at peripheral sites but also kept them motivated by reducing professional isolation during extraordinarily difficult times. The national programs can leverage such platforms to strengthen capacities of treatment functionaries at various levels for both induction and refresher trainings especially in the wake of the COVID-19 pandemic. Scale-up of this e-learning initiative by national programs could help address the demand for accessible, cost-efficient and sustainable continuing professional education for management of other communicable and non-communicable diseases and offer an opportunity for preparedness to provide continued learning through communities of practice, even during unprecedented restrictive scenarios in future.

Ethics approval and consent to participate: The NACP considered this activity to be a programmatic activity for capacity building. This project was approved as a programme evaluation (non-research) by the US Centres for Disease Control and Prevention (CDC).

Consent for publication: Not applicable

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: Existing infrastructure available at NITRD (as hub) and at NACP ART centres (as spokes) was used. Additionally, this project has been partially supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of CoAG #001346.

Authors’ contributions: RA and UA conceived the study; RA, RRA, CD, UA, SA, CH, PKM, VVY designed the project protocol; RA, RRA, VD developed data collection tools. RP, RA RRA, CD, RS, SA, AKP, KSS, SKM, MN, BRK, VVY analysed and interpreted the data; RA and RRA drafted the manuscript; All authors critically reviewed the manuscript for intellectual content. All authors and approved the final manuscript. RA is the guarantor of the paper.

Acknowledgements: The authors acknowledge the contribution made by all members of the NITRD, care support and treatment division at NACO/SACS, staff at CoE/ART facilities, all experts who took the sessions, all participants, SHARE INDIA and ECHO team.

National AIDS Control Organisation & ICMR-National Institute of Medical Statistics (2021). India HIV Estimates 2020: Technical Brief. New Delhi: NACO, Ministry of Health and Family Welfare, Government of India. (http://naco.gov.in/sites/default/files/India%20HIV%20Estimates%202020__Web_Version_0.pdf, accessed on 22 February 2022)
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Table-1: Distribution of sessions by positive feedback response rate in each session

	Positive feedback response rate	No. of Sessions	%
Specific queries were addressed in the session	≥80%	48	81.36%
Specific queries were addressed in the session	<80%	11	18.64%
Topic was relevant to practice	≥80%	56	94.92%
Topic was relevant to practice	<80%	3	5.08%
Session had clarity and ease of understanding	≥80%	56	94.92%
Session had clarity and ease of understanding	<80%	3	5.08%
Session duration was appropriate	≥80%	52	88.14%
Session duration was appropriate	<80%	7	11.86%

Table-2: Perceived mean score improvement in self-efficacy before and after the e-learning initiative

Question	Mean (Baseline)	SD (Baseline)	Mean (Completion)	SD (Completion)	p-value	% Improvement
Identify symptoms of TB in PLHIV?	5.1	1	5.6	1.3	0.03	9.80%
Diagnose and treat TB in PLHIV (adults and adolescents)?	5.1	1	5.3	1.2	0.5	3.90%
Provide prophylaxis for TB (INH) in PLHIV (adults and adolescents)?	5.2	1	5.4	1.2	0.3	3.80%
Diagnose and treat TB in children living with HIV/AIDS?	4.6	1.3	4.7	1.4	0.5	2.20%
Provide prophylaxis for TB (INH) in children living with HIV/AIDS?	4.7	1.2	5	1.3	0.2	6.40%
Diagnose and treat complicated cases of HIV-TB?	4.4	1	4.9	1.5	0.05	11.40%
Assess and manage other co-morbidities in patients with HIV-TB?	4.5	1	4.9	1.3	0.02	8.90%
Educate and motivate HIV-TB co-infected patient for TB prevention and treatment retention?	5.2	1.1	5.5	1.1	0.15	5.80%
Recognize and manage side effects of ARV and anti TB medicines for all patients?	4.8	1.1	5.1	1.3	0.11	6.30%
Manage TB in patients with ART treatment failure?	4.7	1.1	4.9	1.5	0.24	4.30%

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Building communities of practice through case-based e-learning to prevent and manage TB among people living with HIV–India

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