Research projects

Cascade training on adherence to therapy using principles of brief motivational interviewing

Angeni Bheekie, Pat Mayers, Lara Fairall, Jo Stein, Rene English
PALSA PLUS training team, UCT- Lung Institute

Introduction
A plethora of health behaviour change strategies are aimed at improving guideline adherence and cost-effective care. A complex nurse training intervention directed to Free State (TB) co-ordinators is being tested in a large pragmatic randomized controlled trial to improve the quality of care for patients with respiratory condition and HIV/AIDS (PALSA PLUS - Practical Approach to Lung Health and HIV and AIDS in South Africa). It was envisaged that by training co-ordinators in guideline implementation, they in turn would transfer such skills during in-service training of primary care nurse practitioners.

Method
Nine TB co-ordinators received training from the research team on respiratory and HIV/ AIDs guideline implementation. They received multifaceted interactive face-to-face training using specially designed materials that were adapted from national guidelines to aid implementation at clinics. This cascade training and was randomized to 8 Free State clinics (intervention), while 7 clinics received the usual method of guideline implementation (control).

The cascade training programme consisted of a one-week session on the clinical management of common respiratory conditions (upper and lower tract infections, asthma, COPD and TB) and HIV/ AIDS. 3 one-day training support visits, approximately 6 weeks apart focused on facilitative training techniques, approaches to handling emotional burden and adherence to therapy using the principles of brief motivational interviewing (BMI).

The adherence support visit consisted of a feedback session identifying experiences on non-adherence to therapy. Two facilitators with experience in BMI, outlined the main principles and emphasized the importance of guiding the client in taking self-responsibility for decision making. They further role-played scenarios to demonstrate application of BMI in clinical practice. A "how not to do it" session was then followed by a "how to do it" one, using the BMI technique. Thereafter, participants were grouped into 4 and asked to role play scenarios on respiratory and HIV/AIDS therapies using BMI technique. While one participant role-played a patient, the other was an attending nurse, and a facilitator was assigned to each group to analyze the "consultation" for content and use of the BMI technique. The scenarios focused on commonly encountered clinical occurrences: the regular use of inhaled steroids for asthma, side-effect of TB treatment, prophylactic use of co-trimoxazole, and a discordant couple one of whom is on ARV therapy. Structured feedback was obtained from participants on each group's performance. At the end of the visit, participants completed an MI evaluation form.

Evaluation
The effectiveness of this cascade nurse training is being tested in a pragmatic randomized controlled trial in which the quality of care among patients attending the intervention and control clinics will be compared. Further, a qualitative evaluation aims to determine acceptability and integration of the in-service training in primary care clinics.