Trainers' Guide for STS Course

Introduction

The purpose of this document is to provide the course coordinators and trainers for the ‘Course for STS in NTEP’ guidance for planning and executing the training. The targeted trainees for this course would be:

Senior Treatment Supervisor (STS)
Tuberculosis Health visitor (TB-HV)

This training may be provided by utilizing the blended approach where a mix of training methods and modes will be used to deliver content. This would include either in-person/ virtual training or facilitator led/ Self learning/ demonstration and role plays. Training sessions which require hands-on training will be conducted only in a physical setting. Keeping in mind the aforesaid best practices of the Modernized Training System, each State Office may decide to choose the approach which is most suitable for their State.

The training of STS to be conducted at state/Regional level preferably at the STDC.

The batch size for Physical Session/Virtual Sessions should not be more than 25.

For virtual sessions, the trainees will be going through the online content, and attempt quizzes after each module. An instructor-led session will also be conducted for each module. This will help the trainees for better clarification of contents and to address the queries and doubts.

For the training areas which require hand-holding of trainees like demonstration of processes- like patient management in Ni-kshay, filling of various forms, Adherence Management tools, recording information on Public Health action, use of NI-kshay Aushadhi, etc in-person training sessions need to be conducted.

The training course content has 11 modules and 41 chapters. Based on different modalities used for the training, the training delivery should take at least 40 hours.

For the purpose of assessment of trainees, a pretest before the beginning of training, interim quizzes at the end of each module and a post-test at the end of training has been configured in the course content. The certificates are auto-generated for the trainees in their LMS account on successful completion of post-test and their performance in interim quizzes.

Training curriculum / Agenda

Sr.	Module	Chapters	Training Modality	Duration (Hrs)
1	Basics of TB and NTEP	TB & TB Epidemiology NTEP Integration of NTEP with Health System	Virtual	4
2	TB Diagnosis and Case finding	TB Case Finding in NTEP Diagnostic Technologies Diagnostic Network and Hierarchy Approaches to TB Case Finding Active Case Finding Campaign	Virtual	4
3	TB Treatment and care	General concepts in TB Treatment DS-TB Treatment and care DR-TB Treatment and care TB Infection treatment and care TB-Comorbidities and special situations	Virtual	4
4	Adherence Management	Patient Management General Concepts in Adherence Management Adherence Support Adherence recording 99 DOTS Medication Event Reminder Monitor(MERM) Adherence Monitoring and follow-up Action	Physical	4
5	Public Health Action	Patient Support TB Arogya Sathi Application Contact Investigation Counseling and education AIC	Physical	4
6	DBT	General Concepts Processes in DBT	Physical	4
7	Supervision, Monitoring and Evaluation	Supervision Program Monitoring Indicators Monitoring	Physical	4
	Supply Chain Management in NTEP	General concepts in SCM Stocking Norms General Processes involved in SCM	Physical	4
9	Private sector Engagement	Overview of Private Sector Engagement Models for Private Sector engagement Partnership Options Regulations TB Mukt Panchayat Initiative	Virtual	2
10	ACSM and Community Engagement	General Concepts in ACSM Guidelines and Protocols for ACSM activities Community Engagement TB Champion Social Inclusion and wellness activities Engaging Family care givers Pradhan Mantri TB Mukt Bharat Abhiyan		3
11	Training the Health Volunteers and Treatment Supporters			3

Trainers

For this course, following personnel may be appointed as the trainers:

MO - STDC
MO - STC
WHO-consultants
DTO (select)
SDS/DDS Pharmacists (Select)- for Supply chain and drug distribution module.

Eligibility

Trainers are selected based on their ability to conduct training in an interactive and interesting manner. The Trainers should have completed the ‘Course for STS’ and they must possess strong knowledge about the NTEP and the various processes related to patient workflow, Niskahy and Niskahy Aushadhi. The Trainers need to go through the Chapter- wise Training Guide for this Course, provided as an Annexure.

The Trainers should be well versed with the IT systems such as, Zoom (for video conferencing), Swasthya-eGurukul (Learning Management System), Ni-kshay and Ni-kshay Aushadhi.

Chapter wise detailed instructions for Trainers

The aim of providing chapter-wise detailed instructions provides the Trainers with the following:

Module-wise and Chapter-wise, modality that may be adopted (virtual/ Physical/ In-person)
The estimated time to complete the content.
The key messages that a trainer should emphasize upon, while delivering the training
The activities which should be conducted at the end of each chapter / session to ensure learning effectiveness. This may include asking specific questions, demonstrating processes, discussing various forms and equipment. If any Module specific physical visits are required to be conducted, such details are also provided here.

This guiding document will also aid in bringing uniformity with respect to the content and quality of training conducted across the entire state and nation.

Module 1: Basics of TB and NTEP Virtual Session (4 hours)
Chapter 1.1	TB & TB Epidemiology	Virtual Session (60 min)
Emphasis Points	Differences between TB Infection and active TB Disease TB has many determinants- behavioral, socio economic, biological Vulnerable population for TB Concepts of TB Notification Rate and TB Incidence Rate
Post Session Activity	The participants may be asked to (i) enumerate the various determinants of TB and (ii) difference between TB Infection and TB Disease Give an exercise to calculate the Notification rate of a TU. In a TU with a population of 2 lakhs, 100 TB cases were diagnosed and reported during the year 2022.. A total of 90 people with TB were initiated on treatment, 5 died and 2 migrated before initiation of treatment.and 3 could not be contacted at all. What is the annual TB notification rate for that TU in 2022? [ Answer: 50 per lakh] Discuss - Can we call the above obtained Notification figure as the incidence of TB in that TU? If not Why? [Discussion Points: Notification and Incidence are not the same. Notification includes all diagnosed TB cases and reported to the system. It includes both new and previously treated cases. There may be cases diagnosed, but not reported. It is possible that there will be cases in the community not diagnosed at all.]
Chapter 1.2	NTEP	Virtual Session (45 min)
Emphasis Points	Explain what India is committed to achieve in 2025 in relation to SDG related to ending TB. Clarify that the country has preponed the 2030 SDG targets related to ending TB to 2025. Organizational structure of NTEP with broad functions of each institutions (state level and below) Different stages in the patient’s life cycle need to be explained in detail and emphasis on the concept of continuum of care from ‘presumptive TB to post treatment follow up’ Concepts of ‘’Standards of TB Care’’ as a minimum set of care that every citizen in India should receive irrespective of where he/she seeks care from
Post Session Activity	Discuss- ‘What India is committed to achieve in 2025 in relation to ending TB?’’ [Clarify that the country is only trying to achieve the SDG goals related to Ending TB] Discuss- ‘Can Medical College be a PHI?’
Chapter 1.3	Integration of NTEP with Health System	Virtual Session(30 mins)
Emphasis Points	Need for integration of NTEP with the general health system & NHM and how that integration is envisioned .
Post Session Activity	Discuss - "What are the opportunities available to NTEP through Health & Wellness Centers? How could that be materialized”’
Module 2	TB Diagnosis and Case Finding	Virtual Session (4 hours)
Chapter 2.1	Diagnostic Technologies	Virtual Session (30 min)
Emphasis Points	Names of different tests,their uses, advantages and disadvantages
Post Session Activity	Ask what are the advantages and disadvantages of FL- LPA over NAAT?
Chapter 2.2	Diagnostic Network & Hierarchy	Virtual Session (30 min)
Emphasis Points	Network and hierarchy of laboratories and their basic role
Post Session Activity	Ask “ how many sputum collection and transportation facilities are there in their concerned TU? Make one participant explain how it functions and what are the benefits out of it”?- Bring out the following benefits (1) prevents leaks in cascade of care (reduce loss from presumptive TB identification to TB Testing) (2) minimizes patient inconveniences (3) minimize patient Turnaround Time (4) reduce out of pocket expenditure (5) helps in infection control as people with symptoms need not travel
Chapter 2.3	Approaches to TB Case Finding	Virtual Session (30 min)
Emphasis Points	Differentiate between screening and testing. The three approaches may be discussed by giving suitable examples to fit into the three scenarios
Post Session Activity	Discuss the following scenarios and ask the participants which case finding those are (i) Screening for active TB in a Diabetic Clinic & testing those who screened positive (ii) Screening for active TB in an elderly home & testing those who screened positive (iii) Screening for active TB in cancer wards & testing those who screened positive
Chapter 2.4	TB Case Finding in NTEP	Virtual Session (30 min)
Emphasis Points	Diagnostic algorithm for Pulmonary TB- Role of Chest X ray as a screening tool and the need to complete the diagnostic algorithm. Classification of TB on the basis of site,diagnosis, drug resistance
Post Session Activity	Discuss: “What proportion of presumptive TB patients in your TU completes the diagnostic algorithm? What are the implications if the people are not completing the diagnostic algorithm?”
Chapter 2.5	Active Case Finding Campaign	Virtual Session(45 mins)
Emphasis Points	Step by step process in planning and execution of an ACF campaign with special emphasis on identification of target population, need for micro planning and need to prevent the leaks in the cascade of care.
Post Session Activity	Discuss how they monitor the ACF in their TU against ‘Cascade of Care? What are the measures they undertake to prevent the leaks in ‘’Cascade of care’’?
Module 3: TB Treatment and care Virtual Session (4 hours)
Chapter 3.1	General Concepts in TB Treatment	Virtual Session (60 mins)
Emphasis Points	It's an overview chapter explaining the concepts- Fixed Dose Combination, Intensive & Continuation Phase. Process of Treatment Initiation and Transfer of patients
Post Session Activity	Request two participants to demonstrate in Demo Ni-kshay the ‘Transfer’ of patients using (i) Push and (ii) Pull methods.
Chapter 3.2	DS-TB Treatment and Care	Virtual Session ( 30 mins)
Emphasis Points	Regimen and dose of drugs for managing DS-TB for adults and pediatric group and weight bands available Display all FDCs in NTEP and ensure the participants could identify all information related to it Common adverse events of anti-TB drugs
Post Session Activity	Call one participant and ask to explain the step by step process for initiating treatment to a 50 Kg old adult diagnosed with pulmonary TB (Rif Sensitive). Write down all the steps in a flip chart/chatbox/Virtual whiteboard. Ask other members to comment on the missed steps and the order of steps. Call a second participant and ask to explain the follow up for the same patient.
Chapter 3.3	DR-TB Treatment and care	Virtual Session (30 mins)
Emphasis Points	What is UDST? Classification of DR-TB? Regimens available for DR-TB? Levels of facilities where treatment needs to be initiated.
Post Session Activity	Ask participants for doubts and help them clear those doubts

CHapter 3.4	Different DR-TB Regimens	Virtual Session (15 mins)
Emphasis points	Different regimens, constituents and duration ADRs due to different regimens
Chapter 3.4	TB Infection treatment and care	Virtual Session (30 min)
Emphasis Points	Eligible people for TPT Testing for TPT Steps for Ruling out active TB before initiating TPT Adherence monitoring and treatment support for those on TPT
Post Session Activity	Role Play- Counseling for TPT
Chapter 3.5	TB Co-morbidity and special situations	Virtual Session (30 min)
Emphasis Points	Bi directional screening for TB-HIV, TB-Diabetes Need for screening for tobacco and alcohol use among people with TB Nutritional assessment for people with TB. Need for and mechanism of Linkages of people with comorbidity (HIV, Diabetes, Malnutrition, Tobacco and alcoholism)
Post Session Activity	Ask the participants to describe the existing mechanism at their TU to screen TB among the people visiting ICTC centers - how is the screening being done? How is it ensured that all those referred for testing have undergone testing? Discuss if there is any scope for improvement. Ask the participant to describe how diabetes testing is done among people with TB in their TU? What are the steps if a person with TB is found to have diabetes? Who and how is diabetic control ensured for that person? Discuss if there are any ways to improve.
Module 4: Adherence Management Physical Session (4 hours)
Chapter 4.1	Patient Management	Virtual Session (60 mins)
Emphasis Points	How the information of patients are managed through Ni-kshay (Enrollment, Request for Test).
Post Activity Session	Call two participants to demonstrate how they (1) enroll a subject and (2) request for Test in Ni-kshay Make all participants to view their task list in Ni-kshay and discuss how they are going to use the feature
Chapter 4.2	General concepts in Adherence management	Physical Session (60 mins)
Emphasis Points	This is an overview chapter where participants need to understand the (i) General Concepts in Adherence Management such as why adherence monitoring and treatment support is important,(ii) what are the various supports required by a person with TB during TB treatment and (iii) various ways of providing those supports and (iv) various ways to monitor treatment adherence ?
Post Session Activity	Ask one participant to demonstrate how they register treatment supporter in Ni-kshay
Chapter 4.3	Adherence Support	Physical Session (60 mins)
Emphasis Points	Imparting skills to Record adherence in Ni-kshay- Demonstrate the recording of adherence in Ni-kshay. Recording adherence using TB Arogya Sathi Application
Post Session Activity	Call one participant and ask to demonstrate recording adherence using TB Arogya Sathi Application
Chapter 4.4	Chapter: 99 DOTS	Physical Session (30 mins)
Emphasis Points	Need to have 99 DOTS Envelops for this sessions Explain step by step process of adherence monitoring using 99 DOTS (Choosing the envelope, educating the person with TB on 99DOTS, Linking it with Ni-kshay, administering the first dose, troubleshooting)
Post Session Activity	Give the following scenarios and ask them to troubleshoot\ Scenario 1: One of their patients complained that she used to dial the toll-free number every day and used to hear “Thank You” also. But when you check, the Nikshay dashboard is still showing red. Scenario 2: One of your clients with TB called you and told you that his call is not going to the ‘toll free’ number because of ‘insufficient’ balance.
Chapter 4.5	Chapter: MERM	Physical Session (30 mins)
	Need to have a MERM device for demonstration Battery assembly may be explained and the different scenarios to troubleshoot should be explained. The process flow in Ni-kshay(registering the device, setting the alarm and refill time ) should be explained to the participants
	One/more participants may be asked to demonstrate this in Ni-kshay(Demo)
Chapter 4.6	Chapter: Monitoring of adherence	Physical Session (60 mins)
Emphasis Points	Participants need to be empowered to use adherence summary dashboards and interpret the indicators.
Post Session Activity	Request everybody to open their adherence dashboards and comment on their % of 'Average Adherence' of all patients on treatment Request all participants to open their adherence task list and ask their plans based on the task list
Module 5: Public Health Action Physical Session (4 hours)
Chapter 5.1	Patient Support	Physical Session (60 min)
Emphasis Points	Various kinds of support the TB patient needs (nutritional support, psycho social support, support for deaddiction, travel support) and how STS could help in offering the same
Post Session Activity	Give a scenario: A 62 year old woman from a Tribal community affected with TB. Ask all participants to list out all the Government schemes/initiatives which can support her during the treatment period? Write down all schemes in a flip chart/Chatbox/Virtual board
Chapter 5.3	Contact Investigation	Physical Session (60 mins)
Emphasis Points	Step by step process for contact investigations Discuss the steps to record the contact tracing in Ni-kshay
Post Session Activity	Ask one of the participants how contact investigations are happening in his/her TU (Coverage, Quality, Periodicity, Challenges). Ask one/more participants to demonstrate the process in nikshay(Demo)
Chapter 5.4	Counseling and Education	Physical Session ( 60 mins)
Emphasis Points	Basic principles of counseling (DOs and DONTs) Points to be included while counseling of a person with TB
Post Session Activity	Ask participants to comment on the following statements made by STS while counseling a person with TB “I have already informed all people who came to your shop that you are having TB”. (Clue: It's a breach of confidentiality. It should have been discussed with the person with TB first. The person with TB should have been empowered to disclose it to others if required) “If you are not taking the medicines properly, you will definitely die”. (Clue: It's a coercive/threatening language and should be avoided) “ Because you were a smoker and alcoholic, you got TB” (Clue: It's a blame on the person and should be avoided)
Module 6	DBT	Physical Session(4 hours)
Chapter 6.1	General Concepts in DBT	60 mins
Emphasis Points	This is an overview chapter. Various DBT schemes for people affected with TB Various stakeholders while processing DBT (Beneficiary, Maker, Checker) PFMS
Post Session Activity	Re-emphasise the concepts - Maker & Checker; Ni-kshay & PFMS
Chapter 6.2	Processes in DBT	150 mins
Emphasis Points	Explain beneficiary registration, benefit process & benefit approval Processing incentives for NP, private provider, treatment supporter, tribal TB Calculation of benefits DBT reports & registers in Ni-kshay
Post Session Activity	Make every participant open their DBT benefit register and beneficiary register and comment on performance
Module 7	Supervision, Monitoring & Evaluation	Physical ( 4 hours)
Chapter 7.1	Supervision	60 minutes
Emphasis Points	General Concepts of Supervision and basis tenants of a good supervisory process Supervisory Protocols for STS Supervisory roles of MO-TC & DTO at TU
Post Session Activity	Reemphasise the concept of supportive supervision. Get feedback on how some of them plan to change their supervision plan.
Chapter 7.2	Program Monitoring Indicators	120 minutes
Emphasis Points	Nine program monitoring indicators - definitions, how to calculate the indicators, how to interpret the indicators. How to perform a root cause analysis- (1) drill down to the problem using data, (2) perform a person, place, time analysis, (3) explore for potential reasons of low performance through interviews
Post Session Activity	Assignment: Each participant needs to calculate any 3 indicators in their TU based on real time data and interpret those indicators. For one of the low performing indicators, they need to do a root cause analysis and come up with potential solutions. Every participant needs to submit an assignment based on this.
Module 8	Supply Chain Management	Physical (4 hours)
Chapter 8.1	General Concepts	60 mins
Emphasis Points	General Concepts of SCM Principles of SCM Drug distribution flow Nikshay Aushadhi
Post Session Activity	Ask for any doubts from the participants and clarify the same
Chapter 8.2	Stocking Norms	30 mins
Emphasis Points	Buffer stocks and storage norms
Post Session Activity	Reinforce the concepts of buffer stock and storage norms
Chapter 8.3	Supply chain process	150 mins
Emphasis Points	Indenting, Receipt Storage of drugs
Post Session Activity	Request one participant to demonstrate drug indenting through Ni-kshay aushadhi
Chapter 8.4	Drug dispensation Module	30 mins
Emphasis Points	Dispensation of drug using Ni-kshay, adding filling and returning dispensation
Post Session Activity	Request one participant to demonstrate the Ni-kshay dispensation module
Module 9	Private Sector Engagement	Virtual (2 hours)
Chapter 9.1	General Concepts	30 mins
Emphasis Points	Why private sector engagement is important and what is the Vision of NTEP on private sector engagement
Post Session Activity	Recollect Standards of TB Care in India and emphasize that the vision of NTEP with regard to private sector engagement is to ensure STCI to all patients. The choice of where to take treatment remains with the patient. Emphasize that more than the private sector, it is the NTEP who wants to engage with the private sector to ensure that all patients reaching them receive STCI. Tell that TU is a population and ensuring STCI to all cases emerging from that population is the responsibility of STS. STS can engage the private sector to minimize his/her workload.
Chapter 9.2	Models of Private Sector Engagement	60 mins
Emphasis Points	Explain PPSAs, Direct Option for engagement Explain STEPS
Post Session Activity	Ask each of the participants to think what model suits for private sector engagement in their TU and why
Chapter 9.3	Partnership Guidelines	30 mins
Emphasis Points	Emphasis on various options under partnership options
Post Session Activity	Discuss what all partnership options are currently existing in their TUs and what would they want to have
Chapter 9.4	Regulations	30 mins
Emphasis Points	Regulations of Mandatory TB Notification and Schedule H1
Post Session Activity	Discuss how information from schedule H1 could be used? (Clue: Most crucial field in the schedule H1 register is the name of the provider who prescribed it. Information from Schedule H1 register could be used to Identify the provider prescribing the anti TB drugs and prioritize for engagement, Identify missing TB cases)
Module 10	ACSM and Community Engagement	Physical(3 hours)
Chapter 10.1	General Concepts in ACSM	60 mins
Emphasis Points	Differentiate clearly among Advocacy, Communication and Social Mobilization Common approaches for ACSM for TB Elimination
Post Session Activity
Chapter 10.3	Protocols for ACSM activities	60 mins
Emphasis Points	Organising Community Meetings, Peer group interventions, ACSM activities in schools
Post Session Activity	Discuss experiences form 1-2 participants regarding organizing community meetings
Chapter 10.4	Community Engagement	60 mins
Emphasis Points	LSGs and their role in TB Elimination TB Forums and what they can do What role can TB Champions play?
Post Session Activity	Discuss what needs to be done to reduce stigma regarding TB in the community. Encourage everybody to discuss.

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Trainers' Guide for STS Course

Trainers' Guide for STS Course

Trainers

Chapter wise detailed instructions for Trainers