1. 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)

2. Teach to Reach Summit Panel: Learning in the field Alex Rowe, MD, MPH Malaria Branch, Centers for Disease Control and Prevention

3. 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

4. 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)

5. Illustrative results (N=100 study comparisons) Strategy Median effect size (%-points) Supervision + high-intensity training26 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 onlyNear zero

6. 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

7. Days of training Effect size (%-points) 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.

8. 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

9. Extra results