Under a collaborative agreement with the NDoH of SA, our team developed a certificate-based short-course for RR-TB management. The course was designed for healthcare workers (HCWs) in primary health care centers and TB settings, preparing them to plan and offer treatment for RR-TB care in the community. The program provided a detailed overview of clinical management, with special emphasis on treatment initiation at the community level. The course offered continuing professional development (CPD) accreditation from the South African Medical Association. The training events were held throughout South Africa and scheduled in accordance to NDoH and local departments’ needs from February 2017 through July 2018.
Course Structure. The course was organized into a four-day, module-based design, with 3-4 modules per day as follows:
- Day 1 modules – key concepts and definitions; TB and TB/HIV epidemiology; latent vs active disease; differentiation of clinical, epidemiologic and microbiologic features of TB compared to RR-TB.
- Day 2 modules – RR-TB screening and diagnostics; baseline clinical evaluation; and treatment regimens.
- Day 3 modules – RR-TB and HIV co-infection; RR-TB and special populations (i.e., pregnancy, diabetes, substance use); community-based and patient-centered care approaches.
- Day 4 modules – integrated case study and participant case study presentations; infection control practices; RR-TB recording and reporting structure.
Each didactic module included case presentations, group-based interactions and/or facilitated discussion. The course faculty included MDR-TB scientists, MDR-TB and HIV trained physicians and nurses, a nurse practitioner trained in MDR-TB treatment initiation, epidemiologist from the local department of health, as well as patients who successfully completed MDR-TB treatment.
Course Materials Development. The curriculum was developed using SA National TB Guidelines (10), which were based on WHO recommendations (11), and related research (12,13). The course modules were organized to guide the participants through progressively more complicated didactic material followed by case-based application of the corresponding material. All patient scenarios were derived from actual TB, RR-TB or TB/HIV case situations from SA. A participant guidebook accompanied lectures to provide supplemental materials and a pocket guide offered quick reference to the salient clinical points. Each didactic lecture underwent three separate reviews: 1) assessment by the faculty and staff at The REACH Initiative of The Johns Hopkins University School of Nursing; 2) assessment by the NDoH; and, 3) assessment by the South African Medical Association for CPD credits. In each step of review, feedback was obtained with comments and corrections incorporated. Prior to launch, the NDoH adopted the training partners to utilize the approved training package.
Participant Selection. Any healthcare professional was eligible to attend the course as invited by the provincial TB leadership. Invitations were based on strategic needs of the province related to an intended goal of decentralization of treatment services to improve access to care. Participant selection also ensured that all trainings were interdisciplinary and included medical officers, pharmacists and nursing staff.
Evaluation Metrics. Before each training, participants completed a 25 question, multiple choice pre-test to determine knowledge of RR-TB. The pre- and post-test was designed by the RR-TB training team members based on content expertise and the SA clinical treatment guidelines. Prior to use, the instrument was assessed for face validity by the lead physician at the Drug-Resistant TB Program of the South Africa National Department of Health who is responsible for leading the national RR-TB guideline development process. Of the 25 questions, 10 were general knowledge questions about RR-TB and 15 questions required application of material by brief clinical case scenarios. At the conclusion of the training, the same questionnaire was administered to assess change in knowledge as a result of workshop participation. All participants were asked to provide basic demographic information. Qualitative course evaluations were anonymously collected using an open-ended questionnaire with five questions and two yes/no questions. The open-ended questionnaire addressed the programs overall rating, it’s strengths and weaknesses, as well as perceived needs of additional training with the final question giving participants the opportunity to provide additional comments.
Ethical review. This training was implemented as part of public health practice involving educational tests with survey procedures. The Johns Hopkins Institutional Review Board reviewed and approved the project as exempt research (IRB00212633), which did not require consent. However, all participants received an overview letter with the instruction that their completion of the demographic form, pre- and post-test was voluntary and, if completed, was authorization to evaluate the individual’s test score and demographic data.
Data analysis. Data capture was performed using Excel (Microsoft, WA). Descriptive statistics and tests of strength of association (Chi-square, t-test) were calculated using Stata 15 (Stata Corporation, TX). Qualitative evaluations were open text and were reviewed for themes as to opportunities to improve along with additional training needs. Respondents offered open ended responses to “What additional training do you need to initiate RR-TB treatment?” Only participants with completed demographic and matched pre-post tests were analyzed. The cadres of MOs and PN/APPNs were included in the analysis because they have the potential to initiate and/or support RR-TB treatment. The health care professionals excluded from the analysis because they did not identify with initiating patient treatment included: Academic Lecturer (n=2), Clinical Associate (n=1), Community Speech Pathologist (n=1), Enrolled Nurse (n=19), Epidemiologist (n=1), and Pharmacist (n=7). Analysis compared MOs to PNs, and further elucidated PNs, particularly APPNs identified as those having completed both the Advance Course Primary Health Care (PHC) and Short Course Training in Nurse Initiated Management of Antiretroviral Therapy (NIMART).