Impact of peer-trainer leadership style on uptake of a peer led educational outreach intervention to improve tuberculosis care and outcomes in Malawi: a qualitative study

Abstract

Background Little is known about how to build leadership capacity to support implementation of evidence-based practices within health systems. We observed substantial variability across sites in uptake and sustainability of a peer-led educational outreach intervention for lay health workers (LHWs) providing tuberculosis care in Malawi. Feedback from peer-trainers (PTs) suggested that leadership may have contributed to the variation. We sought to assess the impact of PT leadership style on implementation, and to identify leadership traits of more successful PTs, to inform future implementation planning and to identify targets for leadership capacity building. Methods Qualitative study employing interviews with PTs and LHWs at high and low implementation sites, and review of study team and quarterly PT meeting notes. High implementation sites achieved high uptake, sustainability and fidelity of implementation including: close adherence to training content and process, high levels of coverage (training most or all eligible LHWs at their site), and outcomes were achieved with high levels of self reported competence with the intervention among both PTs and LHWs. Low implementation sites achieved limited coverage (<= 50% of LHWs trained), and intervention fidelity. Results Eight PTs and 10 LHWs from eight high and 10 low implementation sites participated in interviews. Leadership traits of more successful PTs included: flexibility in their approach to training, role modeling and provision of supportive supervision to support learning; addressing challenges proactively and as they occurred; collaborative planning; knowledgeable; and availability to support implementation. Traits unique to less successful PTs included: a poor attitude toward their role as PT and a passive-avoidant approach to challenges. Conclusion This study identified leadership traits more common among unit level leaders at sites with higher uptake, sustainability, and fidelity of implementation. These findings provide a starting point for development and evaluation of a leadership capacity building intervention for unit level leaders to support implementation.

Process evaluation of an implementation strategy to support uptake of a tuberculosis treatment adherence intervention to improve TB care and outcomes in Malawi

“…Among LHWs who elected to participate, the primary reasons given were intrinsic motivations, including wanting to improve personal knowledge and skills, and to provide better care and through this to improve patient outcomes. Intrinsic motivation and positive effects of participation in the intervention was also noted in the pilot study 17 31 and companion study, 31 and suggest that emphasis on these outcomes when introducing the programme may help to motivate participation.…”

“…Similar to the stipend issue, it is unclear why lack of interest or confidence was more persistent over time among PTs in the current study. While it is possible this barrier may be of less importance under routine programmatic conditions, based on findings in our companion study 31 addition of leadership training for PTs may be considered to support PTs and improve their effectiveness in this role.…”

“…However, the impact of this addition to the PT training is unclear. Many LHW participants in the process evaluation interviews, as well as, participants in a companion study on PT leadership style, 31 noted receiving and appreciating supportive supervision from their PTs. This suggests that support at this level is feasible and well received, however negative reports with respect to PT supervision suggest that more work is needed to optimise supportive supervision provided by PTs to support implementation.…”

Impact of a tuberculosis treatment adherence intervention versus usual care on treatment completion rates: results of a pragmatic cluster randomized controlled trial

“…LHWs who transferred to non-intervention sites were asked not to share their learning with staff at their new site and to leave their point-of-care tools at their original intervention site (to prevent sharing with non-intervention site staff). In addition, a few LHWs interviewed in the process evaluation (unpublished data) and leadership sub-study reported elsewhere [ 29 ] reported that their training was condensed or incomplete. All sites where cascade training was conducted reported ongoing use of their training and point-of-care tool in provision of care to the end of the study.…”

“…The principal reason for refusal to participate was lack of training stipends. In addition, reports from LHWs in a companion study evaluating the impact of PT leadership style on uptake of the intervention [ 29 ] noted a few cases where PTs did not provide the complete training package. Implementation quality at some sites was low, despite additional (if limited) supports and mentorship provided through contact with the study team and Dignitas trainers.…”