1. Module 11: Community TB Care Image source: Pierre Virot, World Lung Foundation

2. Learning Objectives Explain what is community TB care Explain the rationale and benefits of a TB treatment supporter Describe effective characteristics and tasks of a TB treatment supporter Describe how to train a TB treatment supporter Describe the process for monitoring community TB care

3. What is Community TB Care? Community TB care is one of the efforts of the DOTS expansion strategy Trained and supervised community members provide DOT and TB treatment support to patients Objective is to decentralise TB services beyond health facilities and into the communities –does not replace health-facility DOTS –embraces primary health care approach of community involvement of TB care –makes care more accessible to patients and their families

4. Rationale for Community TB Care (1) Africa has some of the highest TB case rates in the world TB facility and “professional” health worker-based treatment have led to –congestion in hospital and medical departments –overstretching of human, material, and logistic resources Need for efficient and cost-effective strategies to deliver TB services under these conditions Image Source: World Lung Foundation

5. Rationale for Community TB Care (2) Many patients prefer to have care in home-setting Attending daily TB services at health facility can be difficult for –patients who are too sick –patients who live far away Community participation can help foster ownership of TB care and – support for TB patients – reduce stigma towards TB

6. Rationale for Community TB Care (3) Piloted in Botswana with conclusion that it is –feasible –acceptable –cost-effective Community TB care can expand upon existing Home Based Care services Strategy has potential to increase compliance and improve treatment outcomes

7. Who is Eligible for Community TB Care? Community TB care is optional Eligible patients include those –who are very sick –who live in remote areas

8. Patients NOT Eligible for Community TB Care Children (except school aged children who could be taken care of by teachers) Re-treatment cases –these patients are normally put on a reserve regimen which contain injectable streptomycin Patients who have a history of non- adherence

9. Services Treatment Supporters Can Provide (1) Give patients daily supervised treatment Educate and support TB patients Educate and support the community –reduce stigma Assist with case finding and detection –referral of patients for diagnosis –may bring sputum specimens to health facility –collect results

10. Services Treatment Supporters Can Provide (2) Recognition of adverse effects Tracing patients interrupting treatment and helping them return to treatment Support patients throughout entire treatment –support and motivation of patients –direct observation of treatment TB education for patient, family, and community –increase community awareness –use both formal and informal ways –help reduce of stigma

11. Implementing Community TB Care and Roles and Supervision

12. What is Needed to Implement Community TB Care Collaboration and cooperation between BNTP, health facilities, communities, and NGOS Clear roles and guidelines for all service providers including community volunteers Education and counseling of TB patients and families Identification and training of community volunteers A effective system of supervision and monitoring of community volunteers

13. Roles and Supervision (1) The District TB Coordinator Overall responsibility for supervision and coordination of TB community care in the district –train health facility staff on identifying, supervising, and training TB treatment supporters –monitor progress of community TB care

14. Roles and Supervision (2) Health Facility Staff Identify TB treatment supporters Train TB treatment supporters Meet with and supervise TB treatment supporters Image source: Pierre Virot, World Lung Foundation

15. Identifying TB Treatment Supporters

16. Identifying Potential Community TB Treatment Supporters (1) Health facility staff should ask patient Where and when they work Who do they see each day Available transport Is their family supportive or disapproving Do they have suggestions for a convenient and acceptable treatment supporter – a neighbour? a co-worker or supervisor? a community health worker? a village leader? Where and when the patient could meet regularly with a community TB treatment supporter

17. Identifying Potential Community TB treatment Supporters (2) A community health worker who is already trained to be a TB treatment supporter A trained volunteer where patient works A shopkeeper in a local store A former TB patient, living in the same community, who has successfully completed treatment

18. Characteristics of an Effective Treatment Supporter (1) Accessible and acceptable to the patient Willingness to be trained Ability to attend every appointment during regimen (initial phase and, for some regimens, continuation phase) Interest in patient’s welfare and treat patient kindly Carefulness in administering drugs and writing on the TB Treatment Card

19. Characteristics of an Effective Treatment Supporter (2) Respectful of confidentiality Willingness to follow up if any problems occur or if the patient does not come for an appointment Ability to come to the health facility for monitoring and to obtain a re-supply of drugs (or a health worker will need to visit and deliver the drugs)

20. Meet with TB Treatment Supporter Explain basic information about TB and importance of directly observed treatment Review the tasks of a community TB treatment supporter Explain that supporter will be needed duration of regimen

21. Training TB Treatment Supporters

22. Train the Community TB Treatment Supporter Use good teaching methods –Provide information (tell) –Provide examples (show) –Allow for practice Image Source: Sarah England, World Lung Foundation

23. Training: Provide Information Use “A Guide for Tuberculosis Treatment Supporters” to provide Basic TB Information Treatment Supporter’s Tasks

24. Training: Use Examples Demonstrate how to perform tasks Show how to handle drugs Show how to write on patient’s TB Treatment Card cards Image source: World Lung Foundation

25. Training: Allow Practice Ask the TB community supporter to perform the tasks as you watch Give guidance when treatment supporter makes a mistake or is unsure Give praise when TB treatment supporter performs a task well

26. Health Facility Roles for Supervising Treatment Supporter Give patient’s first month of drugs to TB treatment supporter Supervise and re-supply treatment supporter with drugs Copy patient’s TB Treatment Card for treatment supporter –keep original card at health facility –give duplicate card to treatment supporter –update original card with entries from treatment supporter Identify problems and discuss Check when patient is due for follow-up sputum exam or visit to clinic Thank and support treatment supporter Take action if treatment supporter fails to collect drug supply

27. Monitoring Community TB Care

28. How is Community TB Care Monitored? Monitored through the Botswana National TB Programme system Community volunteers complete data collection forms and submit to health facility Health facility completes monthly reporting District TB Coordinator completes Community TB Care Quarterly Reporting Form Image source: Gary Hampton, World Lung Foundation

29. Community TB Care Treatment Supporter Compliance Register

30. Community TB Care Monthly Reporting Form From Facilities

31. Community TB Care Quarterly Reporting Format For Districts