A knowledge translation intervention to improve tuberculosis care and outcomes in Malawi: a pragmatic cluster randomized controlled trial

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.

Effects of social protection on tuberculosis treatment outcomes in low or middle-income and in high-burden countries: systematic review and meta-analysis

“…The other studies (n = 8) occurred in countries out of this category, but referred to as low-income: Malawi 21 Quasi-experimental designs (n = 11) accounted for most of the reviewed studies, followed by RCTs (n = 9) and observational studies (n = 5). Seventeen studies (among then eight RCTs) presented evidences on effects of non-financial interventions for TB patients (lay community health workers or social workers 19,28,31,32,33,34,35 , food assistance 23,27,28,30,36,37 , counselling 22 , "TB clubs" 20 , training programs 26 , social franchising 38 , socio-educational approaches 21 ).…”

“…Nineteen studies were conducted in middle-income countries (13 in upper-middle and six in lower-middle). Four studies were developed in three low-income countries: Ethiopia 19,20 , Malawi 21 and Nepal 22 . Two studies 23,24 were developed in Russia, which is not in low-and middle-income categories, but it is listed between the high TB-burden countries 2 .…”

The ‘Practical Approach to Lung Health' in sub-Saharan Africa: a systematic review

“…The PALSA trials had a higher number of women in both the intervention and control groups, 12 , 13 with the exception of Bachmann et al 15 Patients in Fairall et al, 12 a PALSA study, were older (average age, intervention group 44.9 years vs. controls 44.2 years) than in Zwarenstein et al, 13 the PALSA PLUS trial (35.4 vs. 35.6 years) and PALM/LHW 14 (PALM 39.3 years, PALM/LHW 38.7 years, controls 37 years).…”

“…One study applied the PAL in Malawi integrating human immunodeficiency virus (HIV) care (PALM PLUS), in which half were allocated to PALM PLUS with ‘lay health workers intervention’ (PALM/LHW). 14 …”

Lay Health Workers experience of a tailored knowledge translation intervention to improve job skills and knowledge: a qualitative study in Zomba district Malawi

“…The effectiveness of the intervention in improving TB treatment completion rates was evaluated in the cluster randomized controlled Trial, which showed a non-significant trend for effectiveness [ 8 ]. Pre-post knowledge testing was not conducted due to concerns that LHW fears about ‘testing’ would negatively impact participation in the training.…”