Abstract
BackgroundLay health workers (LHWs) play a pivotal role in addressing the high TB burden in Malawi. LHWs report lack of training to be a key barrier to their role as TB care providers. Given the cost of traditional off-site training, an alternative approach is needed. Our objective was to evaluate the effectiveness of a KT intervention tailored to LHWs needs.MethodsThe study design is a pragmatic cluster randomized trial. The study was embedded within a larger trial, PALMPLUS, and compared three arms which included 28 health centers in Zomba district, Malawi. The control arm included 14 health centers randomized as controls in the larger trial and maintained as control sites. Seven of 14 PALMPLUS intervention sites were randomized to the LHW intervention (PALM/LHW intervention arm), and the remaining 7 PALMPLUS sites maintained as a PALM only arm. PALMPLUS intervention sites received an educational outreach program targeting mid-level health workers. LHW intervention sites received both the PALMPLUS intervention and the LHW intervention employing on-site peer-led educational outreach and a point-of-care tool tailored to LHWs identified needs. Control sites received no intervention. The main outcome measure is the proportion of treatment successes.ResultsAmong the 28 sites, there were 178 incident TB cases with 46/80 (0.58) successes in the control group, 44/68 (0.65) successes in the PALMPLUS group, and 21/30 (0.70) successes in the PALM/LHW intervention group. There was no significant effect of the intervention on treatment success in the univariate analysis adjusted for cluster randomization (p = 0.578) or multivariate analysis controlling for covariates with significant model effects (p = 0.760). The overall test of the intervention-arm by TB-type interaction approached but did not achieve significance (p = 0.056), with the interaction significant only in the control arm [RR of treatment success for pulmonary TB relative to non-pulmonary TB, 1.18, 95% CI 1.05–1.31].ConclusionsWe found no significant treatment effect of our intervention. Given the identified trend for effectiveness and urgent need for low-cost approaches to LHW training, further evaluation of tailored KT strategies as a means of LHW training in Malawi and other LMICs is warranted.Trial registrationClinicalTrials.gov NCT01356095.
Highlights
Lay health workers (LHWs) play a pivotal role in addressing the high TB burden in Malawi
Intervention In addition to the 7 TB focus LHWs trained as peer trainers who continued to provide patient care during the study period, a total of 49 general LHWs were initially reported by peer trainers to have completed the intervention training
This included all LHWs routinely providing TB care at PALM PLUS with LHW intervention sites at the start of the study and ranged from 3–12 per site, with all LHWs who started the training reported by peer trainers to have completed the training
Summary
Lay health workers (LHWs) play a pivotal role in addressing the high TB burden in Malawi. An estimated 4.2 million skilled health care workers, 1.5 million in Africa alone, are needed to address the chronic global shortage of skilled health workers [6]. Shown to improve access to preventative and basic health services, and positively impact some health outcomes [8,9], insufficient training and supervision are recognized barriers to the effectiveness of LHW programs [9]. Despite their widespread involvement in healthcare, evidence on how LHW training and supervision needs may best be met is lacking [7]
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