Positive trends were evident across ECHO and non-ECHO health facilities in our descriptive assessment of pre- vs. post-intervention means for all outcomes (Table 5).
It is not possible to attribute all the improvement (or lack thereof) in the outcomes of interest to implementation of the ECHO program at health facilities. It is plausible that other interventions supported by the Zambia MOH and other implementing partners working on HIV and TB contributed significantly to these achievements.
On the other hand, adherence to ECHO recommendations was mainly limited by lost to follow-up (29.4%) followed by non-availability of the recommended drugs (ARTs) for the cases where drug switch was advised by the subject matter expert. The vast majority of reported reasons for non-adherence to ECHO recommendations were more of health systems rather than client-level factors. Suffice to say, non-adherence was mainly due to circumstances beyond the ECHO site’s control as all sites were willing to implement the recommendations.
Further, the availability of basic laboratory results was a significant challenge in all sites visited as approximately 28% of cases did not have VL results in the medical records at case presentation and about 43.4% did not have creatinine and hemoglobin results at the time of case presentation. The availability of VL, creatinine, and hemoglobin results further declined (39.6%, 20.8%, and 15.1% respectively) at three- and six-months follow-up.
Out of the 53 cases that were assessed, 44 (83%) cases had complete information on health outcomes, 35 (79%) cases recorded positive health outcomes, 9 (17%) cases had negative health outcomes (6 dead and 3 alive but with deteriorating health). Five of the cases with negative health outcomes were from Western Province, two were from Eastern Province. Lusaka and Southern provinces had one case each. Of the 9 negative outcomes, 7 of the cases were male, 2 were female. Non-adherence to recommendations was recorded in five of the cases with negative health outcomes.
The majority of survey participants (69%) reported that they attended 12 or more ECHO sessions. When asked what component of the ECHO sessions they found to be the most useful, the majority (66%) of health workers indicated that the patient case presentations were the most useful as this gave them opportunities to discuss the case collectively with experts at the hub and colleagues from the network, while learning from one another in an inter-professional context. One-fourth (24%) of health workers found the didactic presentations to be most useful as this gave providers opportunities to fill in knowledge gaps complimented by case discussions. Fewer (10%) health workers found sharing knowledge and skills from the ECHO sessions with peers in their respective health facilities useful. Findings showed that none of the health workers surveyed had presented a case for ECHO session. Most participants indicated that patient cases presented by other providers were most useful.
Also, the majority of health workers (90%), comprising 21 clinical officers, 27 nurses, five laboratory personnel, four pharmacy personnel, and one doctor reported that the availability of CPD credits encouraged them to participate in ECHO sessions.
The majority of providers (78%) also reported that enhanced knowledge of HIV care and prevention services through technical updates was the biggest benefit of participating in ECHO sessions, followed by having access to experts at UTH and other health facilities (20.6%) as a factor in enhancing knowledge. Only 1.4% providers expressed participating in ECHO sessions as a benefit (Table 7).
Ultimately, the most common barrier (74%) to participation in ECHO sessions was not having the time to attend due to their workload; 7% respectively reported a lack of awareness of the ECHO session schedules or no interest in the content provided in ECHO sessions as their barriers to participation. (Table 8)
Experiences and Perspectives Reported by Focus Group Discussion Participants
Focus group discussion participants identified a number of factors affecting implementation of the telementoring intervention, some intrinsic to the ECHO approach and others reflective of variations in leadership support and implementing environments across project sites.
1. Enablers Intrinsic to ECHO Approach - Attributes of the ECHO approach that were seen as key features enabling successful implementation included the choice of technology platform and the content, structure, and delivery of presentations, particularly the emphasis on peer interaction.
First, the Zoom technology platform was described as an effective enabler because it was user friendly in that even those cadres with limited technological skills were able to adapt and use the Zoom technology with few difficulties. Several participants perceived Zoom as economical to use because it was accessible anywhere in the country, even in hard to reach places with limited internet connectivity, and noted that it had grown in popularity and use since the start of the COVID-19 pandemic.
Another important strength of the ECHO program was its wide coverage and accessibility. Participants shared that whether one was at work or at home, access was easy, hence it was able to reach many health workers at the same time. ECHO was facilitated by the ease of access even when one was away from the facility where ECHO equipment was installed.
Second, the participants felt that participation was facilitated by confidence in presenters especially when presenters were seen to be knowledgeable, confident, organized, and experts in their field, which inspired trustworthiness in what they were teaching. Additionally, participation was inspired by case scenarios, which related to challenges faced by health facilities.
“One thing that I liked about ECHO is that they introduced a topic, discuss it and then they will do a case study. Then we go through how to handle that case systematically ensuring that all the steps carried out are uniformly done.” – Health worker, Lusaka Province
Topics were also reported to facilitate participation in ECHO sessions, especially when the topics were of interest (related to work of the health worker) or responded to the challenges that the health worker was facing in terms of patient management. For example, topics like hepatitis B and COVID-19 were found to be more interesting to ECHO participants.
“HIV/TB services in my district have improved because of ECHO sessions. We now have proper patient management. For example, we had a case of hepatitis B where after the presentation it was clear that no medication was supposed to be given to the patient and that there were stages of follow-up which were supposed to be made for the patient. These were not planned before the ECHO sessions. So, before the ECHO session a lot of drugs were being wasted to give to hepatitis B patients who were not eligible to be given medication.” –Manager, Lusaka Province
Additionally, the participants noted that sessions were most effective when the presenters were audible and clear, used less jargon, and involved everybody in their facilitation. They also reported that polling questions were important because they enabled them to self-assess what they knew about the subject matter and motivated them to want to know more about the subject. It was also noted that presenters not being dismissive and being respectful helped inspire participation.
Finally, peer interaction was cited as a key enabler for ECHO implementation success. Participants described ECHO sessions as having created an enabling environment that is inclusive but also encouraged participation of all cadres regardless of discipline to contribute equitably, with autonomy and comfort of being heard.
Some participants noted that having access to experts via ECHO sessions gave them confidence to manage difficult cases to consult for help when needed. ECHO linked providers with experts and also enabled health workers to network within and across districts and provinces. These peer networks became important when experts were not available and also for some cadres who reported not feeling comfortable consulting renowned experts.
a. Program and Context-Specific Enablers - Program and context-specific enablers identified by focus group discussion participants included perceived personal and health system benefits to participation, facility culture, and communication.
Some participants shared that they were motivated by perceived personal benefits, such as career development. Most participants recognized that the field of HIV/TB was dynamic and fast evolving thus, ECHO sessions provided them with opportunities to update their knowledge and skills.
“I have never gone for a workshop for third line treatment. It is just the interest, I have just been reading and the ECHO sessions that we were having with professors, they really enlightened us and we are able to manage third line clients.” – Health worker, Southern Province
Some participants at management level noted that capacity that was built through ECHO and peer learning significantly contributed to personnel development in health facilities. As personnel in health facilities learned how other facilities handle difficult cases, they felt motivated and empowered to became confident handling difficult cases that previously they would not treat.
“One scenario that we had was a patient who had a viral load which was not coming down, it was just going up.… I recalled there was a discussion concerning that and they talked about different things that we could do to help our client if he grows up, and at the moment I have seen that things have actually worked well for that client and the viral load has actually come down.” - Manager, Southern Province
Another manager noted that health facilities that participated in ECHO increasingly started using equipment that they had not been using because they did not have the capacity. Sometimes facilities were not using certain laboratory equipment because they had not encountered cases that required such equipment, and in other facilities, ECHO showed the need for orientation on how to use certain equipment.
Facility culture was also identified as a major enabler in ECHO implementation in some facilities, which enabled participation. In these facilities, implementation was helped by broad ownership of the program among staff at all levels.
“…some of them we never even used to know their names. I just knew they existed somewhere and we would fight each other when they come to the ART department. But here we are even having lessons, presentations, training over the weekends and we are all just working as one.” Manager, Lusaka Province
Hence, the ECHO culture helped to bring everybody together, reduced over reliance on ECHO coordinators, and made it a team effort to remind one another on sessions but also made it everybody’s business to ensure that the link was shared. Thus, building an ECHO culture at facility level helped make staff at all levels ECHO champions. Further, it helped push for its implementation leading to improved ECHO implementation.
Facility leadership was also instrumental in ensuring that multiple mediums of communications were used in sharing of the link, such as use of memorandum, posting reminders of session on institutional notice board, sharing of the link using multiple social media platforms, such as WhatsApp. Further, because of strong facility leadership and ECHO culture, other cadres including students were involved in ECHO sessions. Because of good leadership, ECHO has been incorporated not just as a part of the curriculum for student but also as part of student assessments.
In some facilities, active leadership made it a point that those who missed sessions, benefit by participating in symposium and clinical meetings organized at the facility. In addition, facility leadership also tracked those who attended and ensured that the log books were filled in after each session. This enhanced commitment among key stakeholders and in turn helped ECHO implementation. Hub-level leadership was also cited as another key enabler. Participants shared that the practice of hub leadership sharing topics and schedules in advance helped facilitate ECHO implementation.
2. Barriers Intrinsic to ECHO Approach - Focus group discussion participants also identified a number of barriers perceived to be intrinsic to the ECHO approach, though most are factors that could be addressed through context-specific adaptations and support in future programs. Primarily, the centralized coordination of ECHO was reported as a barrier in almost all the provinces. Some respondents were of the view that the centralized system of coming up with topics was a demotivation as some of the issues that were tabled in ECHO sessions did not respond to or answer the critical challenges that providers and facilities were encountering. Other issues were time management, short notice to prepare ECHO cases, need for guidance for foreign presenters on the approved Zambian guidelines in HIV/TB, and how to access recorded sessions.
“You find that the management that is being discussed is not in the Zambian guidelines. So, you find that they are saying give this drug, but the guidelines are saying give this other drug. So, maybe it should be presented in such a way that it suits our country.” – Manager, Eastern Province
“In situations where—maybe in a discussion situation—where you had different views with what the very highest person you have has presented, you start to think, can I argue with my boss or can I dispute the consultant?” – Manager, Southern Province.
While Some participants noted ambiguity in ownership and leadership of the initiative, sharing that when health workers perceive a project as donor driven, rather than nationally-owned, they do not feel compelled to participate.
“When you look at the donors and the partners, the way they decided to introduce the program, they have put it in a way such that the support staff from the partners are the ones that are made to lead these sessions. It would have been better if they had penetrated through the facility management so that it becomes more of a government driven program than a donor driven program. So, once the staff [donors] leaves there will be no one to spearhead the program.” – Manager, Lusaka Province
a. Infrastructure Requirements - The vast majority of respondents reported that internet connection in their area is poor and particularly challenging for rural health facilities. Related to this, power outages were cited as barrier to ECHO implementation. It was reported that load shedding had brought about intermittent power supply that ultimately affected ECHO session attendance. For example, at the time of this study, Chipata in Eastern Province experienced power outages on a Monday.
“Load shedding [is an] issue whereby it is time for ECHO and you do not have power, meaning you will not attend” – Health worker, Chipata
b. Program and Context-Specific Barriers - Many program and context-specific barriers mirrored the enablers identified, reflecting the importance of tailoring capacity-building materials to diverse user groups and the influence of facility-level leadership and working environments on program implementation.
Alongside positive feedback on content, structure, and delivery of presentations reported above, some participants felt that further efforts are needed to make ECHO session more inclusive. First, although the engagement of various cadres and departments in ECHO sessions was highlighted as a factor motivating participation, some respondents noted that key cadres involved in HIV/TB services were not included, namely HIV testing counsellors, community-based volunteers, and peer educators.
“I have noticed there is just one profession which does the presentations, we can have social workers… maybe a nutritionist.” – Heath Worker, Southern Province
In fact, many focus group discussion participants agreed that the topics were too medical (biased towards one cadre: doctors) thus did not reflect the multidisciplinary approach of medical care.
“We are being left out more especially where nursing care is concerned. In a clinical setup, you cannot do away with nursing care because us nurses, we are always with the patient, giving them medication and giving them psychological care until they are discharged.” – Manager, Western Province
“I think we should increase more presentations on children, adolescents, and HIV pregnant women because in Zambia, management of pediatric ART is still a challenge.”– Health worker, Southern Province
Related to this, many felt that the language used in presentation was too technical and too academic for some cadres, even those with prior training.
“When a presentation has a lot of jargons … the discussion goes too much scientific. Therefore, you find that the discussion is only for those at that level, the other cadres are out of the discussion.” – Health Worker, Western Province
“When the one who is presenting is specialized in a particular topic, they are inclined to use the jargons within their specialty, forgetting they are dealing with a mixed group.” –Health worker, Lusaka Province
“Sometimes they are just too academic. I know they are quite detailed for clinical staff but bear in mind that in these hospitals, it’s not everyone maybe who did biochemistry” - Health worker, Southern Province.
Opinions of presenter ability were wide ranging. Some respondents reported that some presenters lacked confidence, displayed lack of expertise in the assigned topics thus resorted to reading slides rather than engaging the audience. There was general concern that the overuse of technical jargon, poor audibility, being judgmental, or ridiculing or belittling participants, especially when providing feedback to case presentations, was a reason why some participants were uncomfortable volunteering to present cases or even participate in ECHO sessions.
Some participants reported that they felt more comfortable speaking and participating in local ECHO (provincial ECHO) than country-level ECHO. Further analysis of the data revealed individual attributes, such as the seniority (big titles) of some presenters during country-level ECHO, as barriers that prevented others who felt inferior from participating. Individual characteristics such as fear of making a mistake (“I will embarrass myself if I say something wrong and the whole country will know”).
As noted above, facility leadership and support were seen as critical components to successful implementation. However, while some participants highlighted facility leadership as a factor encouraging participation, others reported that disinterest in ECHO among facility managers affected participation. In Eastern Province for example, it was heard that some managers had a tendency of scheduling meetings during ECHO time and in some instances, these meeting were scheduled in venues earmarked for ECHO, thus sending a message that ECHO was not a priority.
Some respondents felt that facility support for ECHO was nonexistent, thus resulting in lack of enforcement in ensuring that health workers attended ECHO.
“It’s a bit challenging for me as a departmental manager to convince everyone to come for the meeting, but if It comes from the facility manager, I think it will carry more weight and I really wanted my manager to be here, he is not around… they feel it’s for ART.” – Manager, Eastern Province
Limited infrastructure at facility level was also cited as hindrance to ECHO participation. In cases where conference facilities were available, the venues were sometimes too small to accommodate the numbers. Infrastructure impacted on attendance greatly.
Finally, timing of ECHO sessions was flagged by some focus group participants as a barrier to implementation and an example of where intervention design could be less centralized and more end-user friendly. Specifically, participants were mixed in their views about Monday as an ECHO day—some, especially managers, expressed appreciation and appealed that the day (Monday) be maintained as it was a good day to have ECHO sessions. Considering that Monday is the first day of the week, it accorded them a chance to implement what is learned in the ECHO session. However, most of the respondents felt that that Monday was not a good day for ECHO sessions on account that Monday is a busy day.
“The major drawback is on the days when the ECHO session is actually being held, because you cannot be in the ECHO session and again attend to the clients, so you find that the will be tasks shifting on that particular day, in the end not everyone will actually attend the ECHO session.” – Manager, Eastern Province
Those against Monday shared that most of the critical services are unavailable over the weekend in most facilities hence most cases are pushed to Monday. In addition, some respondents reported that Monday was also a day earmarked for meetings in most facilities, making it less conducive for ECHO. General workload and time constraints were also highlighted as a barrier to ECHO participation. Patient numbers, shift change, and limited workforce were all issues highlighted by medical practitioners as working against them participating in ECHO sessions.