Trainers' Guide for CHO/MPW-PHI Course on NTEP

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 totaling to this duration as appropriate.

Competencies of the Health Volunteer

The following nine 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 Follow-up* 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, enrol 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. Creation/ confirmation/ Issue of Nikshay Usernames to the Health Volunteers
  2. Preparation of Props (Drug Blister packs, PWB, Specimen collection container, falcon tube, Specimen carry bags, IEC Materials)
Chapter wise Trainers notes

The course is divided into three modules, with a total of 12 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 emphasized 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. Basics of TB and NTEP (120 mins)
Chapter 1: Tuberculosis

Emphasis points during the session

  • burden of TB Disease in terms of new cases, deaths and suffering
  • the causative bacteria  
  • mode of transmission, progression to TB disease and the difference between TB infection and active TB disease.
  • 4 major symptoms of Pulmonary TB and how to enquire about these symptoms.
  •  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.    

    Post Session activity:  
  • Facilitator may ask the audience one after the other "50-Year-old ASHA died due to TB. Why did she die?". Write responses on board and classify them into biological, behavioural, socio-economic and occupational determinants.
  • Trainees may be asked about difference between TB infection and active TB disease.
  • Ask any one trainee to enumerate the 4 symptoms and may ask other trainees to explain the meaning of each symptom.
 30 mins
Chapter 2: NTEP

Emphasis points during the session

  • The goals of NTEP.
  • The TB Unit and its significance and the HR posted there.
  • The TB case classification in NTEP
  • The TB patient care cascade and their interaction with the health system.

  • The role of the health volunteer and Treatment Supporter in NTEP

    Post Session Activity:  

  • Ask the participants to enumerate and various stages of TB patient care ecosystem and what all activities are carried out in each of the stage.
 15 mins
Chapter 3-TB diagnosis and Case Finding

Emphasis points during the session

  • Identifying Presumptive Pulmonary TB using the 4 Symptom complex of TB 
  • Process of referral for testing and specimen collection and transport.

  • Discuss the video on the sputum collection.

    Post Session Activity:  

  • Ask the participants to enumerate the 4 chief symptoms of PTB and explain each of the symptom.
  • May ask one of the participants to demonstrate how they would refer a case and sample for testing.
  • Ask the participants about the dos and don'ts regarding sputum collection.
 15 mins
Chapter 4: Nikshay & Treatment Supporter  

 

Emphasis points during the session

  • 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
  • How they will enroll cases, request for test, and add sample details on Ni-kshay.  
     

Post Session Activity:  
1.    The Nikshay Mobile app may be demonstrated.

 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.
  • How the enrolment, referral for testing and sample is collected and transported through Ni-kshay
 10 mins
Quiz #1 The participants need to attempt the quiz based on training content covered in Module 1.  
Participants should complete the quiz before moving on to Module 2. This is a pre-requisite for final certificate		 10 mins
Module 2: Treatment Support and Monitoring of TB Patient (90 mins)
Chapter 5- TB Treatment and Care

Emphasis points during the session

  • Explain Drug Sensitive Tuberculosis and the 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.
  • Explain the DR-TB and the factors that lead to development of DR-TB.
  • Explain the Adverse Drug Reactions to drugs used in DR-TB 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 TB Infection and two therapies for TB Prevention  
     

    Post session activity:

  • Have a practical demo of the drug formulations (blister packs/ pouches/ FDCs) of an Adult and paediatric DSTB Treatment regimen.
  • The participants may be asked to enumerate common ADRs to first/ second-line anti-TB treatment and subsequent action by Health Volunteer.
  • May ask about the options for TPT regimen
 40 mins
Chapter 6- Treatment Adherence

Emphasis points during the session

  • The meaning and importance of Treatment Adherence.
  • The various options available to record patient adherence.
  • Monitoring of adherence in Nikshay
  • The recording of adherence and missed dose in Nikshay portal.
  • The role of Health Volunteers in TB Treatment and care.

Post session activity:

  • One-two participants may be asked about how they enquire about adherence to TB patients. 
  • Adherence recording and monitoring can be demonstrated through Nikshay app or through videos)
 30 mins
Role play #2:

Scenario 1: Mr Ashish who is diagnosed with TB has been initiated on first-line ATT. He was hesitant to start treatment after learning about his TB disease. He lives in an over-crowded chawl with poor hygiene.  
ASHA visits him on Day-5 after his treatment initiation. She speaks to him and convinces him to continue the treatment. She further discovers that Ghanshyam (father of Ashish) who has diabetes is also living in the same household.

Probes: 
1. Whether DBT has been initiated or not 
2. Identification of ADR. (The different ADRs may be explained and enquired about) 
3. Importance of adherence 
4. Contact tracing also needs to be carried out 
5. TPT and its eligibility. 
6. Counselling about TB to Ashish and his family. 
7. The need to control blood sugar of Ghanshyam 

Scenario: 2: ASHA visits Ashish’s house after 7 weeks after his treatment initiation. He is now feeling healthy. His TB symptoms have subsided and he has gained weight. He is now thinking about taking up some construction work in some far off place in Mumbai.

Probes  
• Identification of ADRs if any 
• Change in weight and accordingly change in dosages. 
• Importance of follow-up at DMC for end of IP lab investigation. 
• The option of transferring the treatment centre for TB care and management.  
• Importance of adhering to the ongoing treatment and recording it electronically.

Key message at the end of role play : 
In the form of summary and important areas to be covered while visiting a patient after his treatment initiation. Need to take healthy food and even if they feel healthy, they shouldn’t stop the treatment

 10 mins
Quiz #2 The participants need to attempt the quiz based on training content covered in Module 2.   
Participants should complete the quiz before moving on to Module 3. This is a pre-requisite for final certificate		 10mins
Module 3: Patient Support (120 mins)
Chapter 7 - Public Health Action

Emphasis points during the session

  • The concept of Public Health action
  • Various components of PHA carried out under NTEP for a diagnosed TB patient
  • The contact tracing and investigation carried out for TB patient under NTEP
  • Tasks are carried out by Health Volunteers on home visit to a TB patient
  • The meaning of Treatment Supporter and who qualifies to be TS to a TB patient

Post Session activity

  • Ask the participants to enumerate the 6 public health actions that are carried out after the TB Notification
  • Ask other participants to explain each of the PHAs
 25 mins
Chapter 8: TB Arogya Sathi Application

Emphasis points during the session

  • 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 TB Arogya Sathi App may be demonstrated to participants or videos can be displayed at the end of session.
  2. The use of TB Screening tool in TB Arogya Sathi app may be demonstrated and the utility of this tool in enrolment of presumptive TB. 
  3. Participants may be asked to demonstrate the use of application and clear their doubts.
 20 mins
Chapter 9- 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

Post Session activity

  1. Give the participants different scenarios(Like pre-treatment/During treatment/post-treatment) and Ask the different participants about the components of counselling at different scenarios
 20 mins
Chapter 10- Social inclusion and wellness activity
  • 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
 20 mins
Chapter 11: 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 HVs in Community engagement.

Post Session activity

  • Ask the participants, in what ways the TB Champions help the TB patients
 20 mins
Chapter 12: 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
 

 

Roles and responsibilities of Key Stakeholders  

Please refer to the general roles of various stakeholders for training of Health Volunteers (click here). 

Apart from these general roles, the state NHM has an important role to play in the training of Health Volunteers, especially those who are ASHAs in the state. 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.