Contact for this presentation:

Alexander K. Rowe, MD, MPH

Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health

Centers for Disease Control and Prevention

Mailstop A06

1600 Clifton Road

Atlanta, GA 30329

United States

Telephone: 1-404-718-4754 Fax: 1-404-718-4815 Email: axr9@cdc.gov

Saved as: HCPPR Phase 2\Trips\2015_11 Seattle Vax Learning Summit\HCPPR Teach to Reach Summit BMGF 2015 v1.ppt

last updated: November 1, 2015

Health Care Provider Performance Review

(Presentation at the Bill and Melinda Gates Foundation’s summit “Teach to Reach: Innovative Methods for Immunizations Training”, November 2, 2015,

Seattle, Washington)

Teach to Reach Summit

Panel: Learning in the field

Alex Rowe, MD, MPH

Malaria Branch,Centers for Disease Control and Prevention

Learning in the field

• Focus of Teach to Reach is on training & learning

• In low- and middle-income countries (LMICs), training often occurs in classroom setting

• Panel explores approaches outside classroom to improve training and learning, with ultimate goal of improving health worker (HW) practices

• Panelists will describe their approaches, then a conversation to learn more (note your questions)

• To provide context on improving HW practices in LMICs: results of large systematic review

Health Care Provider Performance Review

• Systematic review of the effectiveness of strategies to improve HW performance in LMICs

• Investigators: CDC, JHU, MSH, WHO, Harvard

• Includes any quantitative study of effectiveness of any strategy to improve HW performance in LMICs

• “HW” broadly defined: public or private-sector HWs in hospitals, clinics, or communities

• Eligible study designs: controlled trials and ITS

• 497 studies from 1960s to late 2000s; update underway

• Following results on improving any HW practice

• Effect sizes are %-point change (e.g., intervention increases from 40% to 50%, effect size = 10 %-points)

Illustrative results (N=100 study comparisons)

StrategyMedian

effect size (%-points)

Supervision + high-intensity training 26

Patient/community support + strengthen infrastructure + regulation/governance + other mgt techniques + supervision + low-intensity training

25

Patient/community support + low-intensity training 13

Group problem solving + low-intensity training 12

High-intensity training only (>5 days + interactive edu) 12

Low-intensity training only (<5 days or no interactive edu) 8

Supervision only 7

Printed or elec. information or job aids for HWs only Near zero

• Analysis of 96 studies to understand what makes training more or less effective

• Interaction between train duration & topic complexity:

– Longer training seems to increase effectiveness by 2 to 3 %-points per added day for training on multiple health topics

– But not for single-topic training (no sign. association)

• Clinical practice, use of multiple educational methods, and on-site training might improve effectiveness; more research needed to confirm

Factors associated with training effectiveness

Days of training

Effe

ct s

ize

(%

-po

ints

)

Training duration versus effect size among studies with training <20 days +/- other

components

Single topic (essentially flat)

Multiple topics

Note: Predicted effect sizes adjusted for other strategy components, baseline, and on-site training.

Conclusions

• Many studies exist on many strategies in LMICs

• To improve HW practices:− Training alone tends to have modest effect

− Training + other components (e.g., supervision) might be better

− Effectiveness of training seems to depend on duration and topic complexity

• To date, importance of training methods, attributes of trainers, and training location are unclear—perhaps because of limitations in how research is reported

• Panel will provide additional, detailed insights on training and learning outside of the classroom

Extra results

Supervision + high-intensity training (17/8; BD) 26.2

Patient and community support + strengthen infrastructure + regulation/governance + other management techniques + supervision + low-intensity training (4/1; BDb) 25.0

Patient and community support + low-intensity training (6/3) 13.0

Group problem solving + low-intensity training (6/1; BD) 11.9

High-intensity training only (10/4) 11.6

Supervision + low-intensity training (29/12; BD) 11.4

Patient and community support + other management techniques (3/2) 11.3

Low-intensity training only (39/16) 7.9

Group problem solving only (14/5; BD) 7.0

Supervision only (12/6) 6.9

Patient and community support + supervision + low-intensity training (5/2) 6.7

Regulation/governance + other management techniques + supervision + low-intensity training (3/2)

5.1

Supervision + printed or electronic information or job aids for HCPs (3/2) 4.9

Printed or electronic information or job aids for HCPs only (6/4) –3.2

–10 0 10 20 30 40 50

Effect size (%-points)

60

Median MES and interquartile rangeStrategy (no. of comparisons / no. of comparisons with low or moderate risk of bias) Median MESa