Trainers' Guide for Health Volunteers Course

Trainees

The targeted trainees for this course are generally those persons at the community level who would be interacting with the population for the purpose of on ground TB activities related to awareness, screening and Treatment Support. These may include:

  1. ASHA Workers
  2. Volunteers from NGOs, Community Representatives/ Youth Volunteers
  3. TB Champions / Survivors/ Family Members
  4. Workplace Representatives who volunteer for becoming focus for TB Services
  5. Educators/ Teachers from Schools and Colleges

 

Trainers

The following cadres are supposed to be trained to become trainers on this course.

  1. STS
  2. TB HV
  3. MO-PHI
  4. MPHW/ Block Coordinators (NHM trainers)
  5. DPC/ PPM Co-ordinators
  6. NGO coordinators/ Supervisors
  7. Representatives from Private/ Corporate sector

The capacity of these trainers to conduct the training for health volunteers will be in-built into their training and is considered as one of their essential competencies.

Training Methods

Teaching and discussing the course content using the standardised training content available on the NTEP approved LMS (such as Swasth-eGurukul). This training may use blended training delivery methods that are appropriate to the local context. This would include a mix of the following options

  1. Traning Premises
    1. In-person
    2. virtual 
  2. Mode of delivery
    1. Facilitator led
    2. Self learning
    3. Demonstrations
    4. practical exercises. 

In the blended mode, an instructor-led session should be conducted for each chapter. Simultaneously the trainees would go through the content available online themselves according to the schedule. Trainees need to attempt the quizzes after each chapter/module. 

At the end of each chapter/session the trainer/ facilitator should summarise the key messages of the chapter by engaging trainees through questions and discussions. The discussion should focus on aspects related to the competencies listed below. These sessions should also help the trainees to clarify doubts and queries. 

For the training areas which require hand-holding of trainees like to perform actual processes such as filling of forms, counselling/ addressing stigma, screening, sample collection, adherence monitoring, a demonstration/ role play mode may be adopted.

The duration of training content including discussions/ demonstrations/ role play, pre/post training assessments, is expected to be completed 6 hours. The course coordinator may schedule the course in multiple sessions totalling to this duration as appropriate.

Competencies of the Health Volunteer

The following ten competencies are important to a health volunteer. 

Competency Assessment Protocol

1. Talk about TB, including

  • Being an infectious respiratory disease
  • It is curable
  • Diagnosis of TB and Diagnostic services available in the Govt
  • How to prevent TB (Ventilation, Sunlight, Cough etiquette)
 Check ability to discuss with general public about TB and awareness of patient family members regarding TB during home visits.
2. Screen for TB using the 4 symptom complex Check ability to screen a patient during house visits.
3. Refer for diagnosis to the nearest TB Testing Centre Check ability to counsel patients, refer them to the nearest TB Diagnostic centre for TB Diagnosis, and record the referral during house visits.
4. Quality Sample collection and transportation 

Check ability to, provide sputum cups to patients, spot and early morning sputum, counsel TB patients on good quality sputum collection, and transport the sample to the nearest health facility during house visits.

May review with TB Diagnostic centre regarding quality of samples provided by the particular volunteer.
5. Record and Monitor Treatment adherence for TB Treatment, TPT *

Check ability to record doses taken, missed doses, and initiate patient retrieval incases of missed doses during house visits.

May also review Nikshay Adherence scores of past or presently linked patients

6. Counsel patients *, and their family for 

  1. treatment adherence, 
  2. nutrition, 
  3. ADR
  4. addressing stigma
 Check ability to counsel a patient on the 4 aspects during patient visit.
7. Refer for ADR management* Check ability to actively check for ADR during patient visit and any linked patient remarks regarding how ADR was managed for them.
8. Post Treatment Followup* Check whether up to two previously linked (Treatment completed) patients have all their post treatment follow up due completed.
9. Use Nikshay for performing the actions related to the above Check ability to login, enroll and refer patients to health facilities, sample collection and transportation and also mark treatment adherence in Nikshay during patient visit.

The five (first four and last one) are core competencies of all volunteers while the remaining 5 (marked with *) are core competencies only if the volunteer acts/ intends to act as a treatment supporter.

The knowledge and training related to these competencies will be provided through the Course for Health Volunteers on NTEP and assessed through the pre and post test assessments/ quizzes.

Competency assessment needs to be done periodically(once in two years) or at the time of registration or initiation of the treatment regimen.

Pre-training Preparation

Before starting a batch of training, the following preparations need to be completed.

  1. Confirmation of participants, trainees, trainers, venue, Training modality, equipment etc, related orders/ communication, instructions on (mobile devices, platform, registration process).
  2. Approvals on any TA/DA to be disbursed as per state policy
  3. Registration/ Enrollment of Trainees and batch formation on TIMS and on the LMS.
  4. Creation/ confirmation/ Issue of Nikshay Usernames to the Health Volunteers
  5. Preparation of Props (Drug Blister packs, PWB, Specimen collection container, falcon tube, Specimen carry bags, IEC Materials)
  6. Internet connectivity facility, and audio visuals at any training sites
  7. Basic Facilities (Seating, toilet, canteen/ lunch area, drinking water)
  8. Refreshments
Chapter wise Trainers notes

The course is divided into three modules, with a total of 11 chapters, each with specific learning and training objectives in alignment with the competencies of the person.  
The different scenarios and probes for the conversation and discussion have been covered in details at relevant sections. Three standard role plays have also been incorporated at the end of each module in the training course.

Session Activity Duration
Session-1 (Introduction)

Introduction and Overview of course  
(The course structure should be explained that there are 3 modules and modules are further divided into chapters)

NOTE: This session may be used as an ice-breaking session and to establish a rapport with the participants. It may also be emphasised here the importance of pre-test, quizzes and post-test assessment to successfully finish the course and obtain the certificate.

 5 mins
Pre-test assessment Note: This is Mandatory before proceeding with course content 10 mins
Module 1. Review module objectives with the participants and proceed to chapter wise content
Chapter 1
  • Explain the TB disease and its significance in public health space.  
  • Explain the burden of TB Disease and efforts that need to be taken to fight this disease. (the Goal to end TB by 2025 may be mentioned here)  
  • Explain the causative organism of TB disease, mode of transmission and  its progression to active TB disease  
  • Explain the types of TB disease on the basis of sites of TB disease. The various sites of EPTB may be mentioned and explained in local language/context.  
  • Explain the difference between Tb infection and active TB disease  
  • Explain DS-TB and DRTB; various factors for development of DR-TB and difference between the two.  

    Post Session activity:  
    1. Trainees may be asked about the various risk factors for developing TB disease.  
    2. Trainees may be asked about difference between TB infection and active TB disease.
 20 mins
Chapter 2
  • Explain the various first-line anti-TB drugs, the two treatment phases, their significance and duration in DSTB treatment.  
  • Explain the FDC used in NTEP with emphasis on age and weight bands  
  • Explain the different TB case types in NTEP  
  • Explain the importance of Follow up during the course of Treatment and post treatment completion  
  • Explain the various treatment-outcomes for TB patients  
    Explain the role of CHVs in identification of ADRs and management of minor Adverse Drug reactions in Home-based care and prompt referral for serious/life-threatening ADRs to higher centres.  

    Post Session Activity:  
    1. Ask the participants about various drugs available for treatment of DSTB, treatment duration.  
    2. Ask the participants to enumerate various ADRs and their management in home-based care.
 15 mins
Chapter 3-T.B Treatment and Care
  • Explain the various first-line anti-TB drugs, the two treatment phases, their significance and duration in DSTB treatment.  
  • Explain the FDC used in NTEP with emphasis on age and weight bands  
  • Explain the different TB case types in NTEP  
  • Explain the importance of Follow up during the course of Treatment and post treatment completion  
  • Explain the various treatment-outcomes for TB patients  
  • Explain the role of CHVs in identification of ADRs and management of minor Adverse Drug reactions in Home-based care and prompt referral for serious/life-threatening ADRs to higher centres.  

    Post Session Activity:  
    1.    Ask the participants about various drugs available for treatment of DSTB, treatment duration.  
    2.    Ask the participants to enumerate various ADRs and their management in home-based care.
 20 mins
Chapter 4: Nikshay & Treatment Supporter

 
  • Explain about the Nikshay portal and various features available in it which are relevant to treatment-supporters
  • Explain the trainees the pre-requisites and process to get themselves registered on Nikshay platform
  • Explain the trainees about the TB Arogya Sathi Application, its multilingual interface, various information available in it and how TB patients can use it to mark their adherence in it and see their DBT status in the application.
     

Post Session Activity:
1.    The Nikshay Mobile app and TB Arogya Sathi App may be demonstrated to participants or videos can be displayed at the end of session.

 20 mins
Role play #1:

A short role play with the trainees to explain the process of screening and case finding, identifying the presumptive cases, and referring them to the nearest DMC for TB diagnosis. The trainer may act as the case/patient and one participant may act as an ASHA.

Scenario Brief

  • On a routine community visit, ASHA came to know about Ashish who works in a brick kiln on daily-wages. Ashish has been coughing and unexplained weight-loss for more than a month. He’s also reluctant to get tested and is relying on a nearby Pharmacist to get a cure for his long-standing cough issues.

Probes:

  • Identification of vulnerable population
  • Enquiring about the chief symptoms of Pulmonary TB and signs and symptoms of EPTB (with constitutional symptoms life fever, night sweats and weight loss)
  • Information about nearest testing facilities and process of sputum collection
  • Provision for free diagnostic and treatment services and patient support for TB patients.
  • Educating the patients and family about the signs and symptoms of TB disease and addressing their doubts and concerns.
 10 mins
Quiz #1 The participants need to attempt the quiz based on training content covered in Module 1. Each participant has three attempts to pass the assessment. 
Participants should complete the quiz before moving on to Module 2.This is a pre-requisite for final certificate		 5 mins
Module 2: Treatment Support and Monitoring of TB Patient
Chapter 5- DS-TB Treatment and Care
  • Explain Drug Sensitive Tuberculosis and treatment phases
  • Describe the treatment regimen for Drug-Sensitive TB (DS-TB) – Adult FDC & Paediatric formulations
  • Explain the patient flow for DSTB Treatment

  • Explain the various Adverse drug reactions and their management
     

    Post session activity:
    The participants may be asked to enumerate common ADRs to first-line anti-TB treatment and its management at home based care.

 20 mins
Chapter 6- DR-TB Treatment and Care
  • Explain the Drug Resistance Tuberculosis (DR-TB) and factors for development of DR-TB.
  • Explain the various types of Dr-TB regimen and Describe Drug Resistance Tuberculosis (DR-TB)
  • Explain the types of DR-TB regimen to make the treatment supporters aware of the names of different regimens available in DR-TB and importance of following up with these patients.
  • Explain the Adverse Drug Reactions to second line treatment and its identification, management and timely referral to health facility. (It may also be emphasized here that the DR-TB treatment is more complex and involves more toxic drugs, hence ADRs are more frequent and there is need to identify the ADRs early and manage these at nearest health facilities/referral centre to N/DDR-TB centre.)
  • Explain the patient flow for DR-TB Treatment

Post session Activity:

  • May ask the participants to enumerate various ADRs due to DR-TB regimen and signs of identification and further management and referral.
     
 20 mins
Chapter 7- TB Preventive Treatment
  • Explain about the TB infection and at-risk populations who are more susceptible for TB infection
  • Explain about the available tests to detect TB infection
    Explain about the patient flow for TB infection.
  • Explain about the details of TPT and eligible population

 

Post Session Activity:

  • The participants may be asked about the eligibility of cases for TPT
  • May ask about the options for TPT regimen 
 15 mins
Chapter 8- Treatment Adherence
  • Explain the meaning and importance of Treatment Adherence.
  • Explain the various options available to record patient adherence and monitoring of adherence in Nikshay
  • Explaining and demonstrating the recording of adherence and missed dose in Nikshay portal( It can be demonstrated through Nikshay app or through videos)

Post session activity:

  • One-two participants may be asked about how they enquire about adherence to TB patients 
 20 mins
Chapter 9 - T.B & Comorbidities & Special Situation
  • To explain TB is an opportunistic infection in people with weakened immune systems
    Explain why people with conditions such as HIV, Diabetes, malnutrition is at increased risk of developing TB
  • Explain the concept of bidirectional screening and how it is carried out.
    Explain the impact of smoking & alcohol abuse on T.B and its treatment outcome
  • Explain the screening steps and principles of management in patients with TB and other concurrent conditions like HIV/Diabetes/Malnutrition/COVID-19/Pregnancy and Lactation.
     

Post session Activity:

  • The participants may be asked to enumerate the various comorbid conditions where bi-directional screening in recommended.
 20 mins
Role play #2: Scenerio 1: The ASHA worker visits a DS-TB patient’s home 5 days after his ATT initiation for
Counselling about TB treatment, treatment adherence  and ADR
Contact tracing
DBT
Scenario: 2: The ASHA worker visits a DS-TB patient’s home after 7 weeks post initiation of treatment.		 10 mins
Quiz #2 The participants need to attempt the quiz based on training content covered in Module 2. Each participant has three attempts to pass the assessment. 
Participants should complete the quiz before moving on to Module 3. This is a pre-requisite for final certificate		 10mins
Module 3: Patient Support
Chapter 10 - Public Health Action
  • Explain the concept of Public Health action
  • Explain the various components of PHA carried out under NTEP for a diagnosed TB patient
  • Explain the contact tracing and investigation carried out for TB patient under NTEP
    Explain what all tasks are carried out by Community Health Volunteers on home visit to a TB patient
  • Explain the meaning of Treatment Supporter and who qualifies to be TS to a Tb patient
  • Explain about the various SMS Notifications from NTEP to a TB patient.
 25 mins
Chapter 11- Counselling
  • Explain the importance of TB awareness generation in community and how it is carried out in community
  • Describe counselling for TB patients, at what stages it is carried out and what components are explained during different stages of TB treatment and care
  • Explain Do's and Don'ts for Patient Communication
    Explain Nutritional Counselling and its importance related to TB patients
 20 mins
Chapter 12- Social inclusion and wellness activity
  • Explain the various determinants of TB disease (classified into Biological, behavioural, Socio-economic and occupational determinants)
  • Explain about the vulnerable populations for TB
    Explain about the Stigma and discrimination faced by TB patients and its adverse effects at individual level and community level.
  • Explain the gender aspects of TB and hoe to address gender inequalities.
  • Explain about various wellness activities meant for TB patients
  • Explain about the Psychological support and various rehabilitation services for TB patients
 20 mins
Chapter 13: Community Engagement
  • Explain the meaning of community engagement and its importance in TB care
  • Explain about the various strategies of Community engagement in NTEP
    Explain about the TB champions
  • Explain the role of CHVs in Community engagement
    Explain the role of CHVs in Community mobilization
 20 mins
Chapter 14: Linkages to Social Support Scheme  Explain the meaning of DBT
Explain the DBT schemes in NTEP including NPY, Tribal SS, TS honarium and incentives for notifications and outcomes
Explain the various criteria for availing DBT Scheme benefits under NPY		 10 mins
Role play #3:

Scenario: 

A newly diagnosed TB patient initiated on treatment comes to his hometown for home based care and treatment. ASHA worker visits his home to verify his address and upon enquiring with neighbours she learnt that Ashish is being stigmatised for contracting TB and his family is being discriminated against. Now ASHA has to give correct information regarding TB to the neighbourhood.

Probes:
Correct information about TB
Appreciation for Ashish to initiate the treatment early.
Motivating the community to support Ashish and his family.
Counselling to Ashish and his family to prevent TB infection.
Complete PHA
Precautions to be taken while visiting a TB patient’s home

 15 mins
Quiz #3: Post - Test

All module content will be covered in this quiz. 

Completion of this final quiz successfully, along with the two quizzes in-between the course is mandatory for certificate generation   

 10 mins
Planning Monitoring and Evaluation of Health Volunteers training.  
  • Planning includes the following activities
    • Creating and maintaining Database of Potential Trainees  
    • Creating and maintaining Database of Trainers  
    • Preparing batches and Training calendar  
  • Monitoring includes the following activities
    • Registration/ enrolment/ attendance  
    • Pre and post-test assessment comparison,   
  • Evaluation and QA includes the following activities
    • Post training participant feedback  
    • Quality of training assessment by Observer    
    • Ongoing Competency assessment and identifying need for re-/update Training

 

Roles and responsibilities of Key Stakeholders  

 

State authorities (STDC Director & STO)

The STDC director and the STO are responsible for the overall planning, execution and monitoring and evaluation of Training in the state. Specifically, they have the following roles:

  • Approve the training plan and secure necessary resources through state PIP for the execution of training

  • Monitor the execution of the training and take necessary actions for the smoot conduct of training.

  • Coordinate with Central TB Division and relevant partners such as The Union and ECHO working in the area of training as necessary. 

  • STDC to work closely with the Central TB Division to translate the courses into local language for increased acceptability

State NHM

The state NHM needs to ensure that all the ASHAs are being trained on TB and NTEP as per the standard training content.  The state ASHA cell at the NHM, should ensure that the following steps are being taken:

  • Support STDC/ STC in planning the training and inclusion in PIP 

  • Prepare and share the list of ASHA’s in the prescribed format with the respective STDC Team

  • Guide and provide directives to the respective District/ Blocks to deploy ASHA’s along with concerned supervisors to ensure active participation

Course coordinators (at STDCs)

The course coordinator is overall responsible for planning and execution of the training course across the state. The broad responsibilities are…

  • Course Coordinators in consultation with the state authorities at STC, STDCs and NHM are responsible for planning the training and provision in PIP for the state

  • Preparation of training calendar, scheduling and executing the courses according to the state Training plan 

  • Coordinate with facilitators/trainers and respective district/ institutions/ authorities for smooth execution of the training

  • Maintenance of Training databases in of all the staff of the state, facilitators and training resources

  • Supervision and monitoring of the training in order to ensure quality of training

Facilitators / Trainers

The facilitator or trainer is responsible to deliver the quality training as per the standard operational guideline in timely manner. 

  • Act as the trainer and conduct instructor led sessions

  • Facilitate sessions in between content, such as role plays and discussions

  • Moderate the discussion board and answer trainee queries

  • Select suitable modes of training execution in consultation with the state authorities

  • Coordinate with the course coordinator and support in preparing the training calendar 

Role of DTO

The DTO and district health authorities should facilitate the training by:

  • Identifying and line list of trainees that require training or re-training.

  • Support the state level Course Coordinator in maintaining the training database and ensuring that it is updated.

  • Provide local support of training to ensure enrolment and completion of various stages of the course as needed