Follow Us
Training
Training for health care providers—often referred to as continuing medical education (CME) when referring to in-service training for physicians, nurses, and other health care professionals—has traditionally employed short courses, conferences, seminars, medical rounds, small group sessions, workshops, tutorials, and other didactic methods to transfer clinical and other information to individuals and groups. Numerous reviews, drawing primarily on studies in North America, have concluded that formal CME without support to enable or reinforce standards-based performance in actual practice has little or no impact on provider performance. However, when training events were complemented by other interventions to reinforce compliance, performance improvements were more likely to be demonstrated. Wensing and Grol (1994) found that group education interventions to induce adherence to standards in primary health care had little or no impact on their own, but when combined with feedback interventions, they enhanced the impact of feedback by providing the knowledge and skills necessary.
Methodologically rigorous evaluations of the impact of training on primary health care worker performance in developing countries are few, but published studies show mixed evidence for the effects of in-service training on performance according to standards. Most studies reporting positive effects demonstrate evidence of only short-term knowledge or behavior gains, without data on long-term retention (Elder et al., 1992; Naimoli et al., 1996; Santoso, Suryawati, & Prawaitasari, 1996). Rowe et al. (2000) examined factors associated with correct treatment of young children with malaria in the Central African Republic; the study identified significant predictors of correct performance in 204 observed cases of fever. It found that in-service training was not significantly associated with adherence to treatment standards. In contrast, Baig and Thaver (1997) found that training in diarrhea case management in Pakistan was significantly associated with correct assessment and diagnosis performance, but not with adherence to treatment standards.
Formal evaluations of health worker performance following a nine-day World Health Organization (WHO) training in the IMCI algorithm (which includes the provision of wall chart reminders and recording forms designed to facilitate IMCI-based performance) show that health workers achieve modest to good performance for assessment and treatment tasks with mildly and moderately ill children, but lower performance scores for those with severe illness. The fact that IMCI training provides trainees with reminders for use in their work place may contribute to its effectiveness in achieving standards-based performance, at least in the short-term. Heiby (1998), in his review of lessons from the implementation of IMCI in developing countries, argues that performance should be reinforced through the incorporation of reminders, job aids, and the ongoing monitoring or audit of health worker IMCI performance.
Despite the accumulated evidence pointing to the lack of effectiveness of traditional didactic training, expert-led teaching still prevails as the most common form of CME in developing as well as developed countries. However, the influence of adult learning theory on undergraduate and postgraduate medical education has recently resulted in increased interest in and application of experiential learning methods and alternative educational formats, including inter-professional education, small group learning, learning contracts, telemedicine, and using the Internet to link isolated providers with university resources.
One such method, problem-based learning, emphasizes the study of clinical cases in small discussion groups, collaborative independent study, and the application of deductive reasoning as opposed to mastery of factual knowledge. Problem-based learning enhances the transfer of concepts to new problems, increases interest in the subject matter, and develops self-directed learning skills.
Another innovation with the potential to improve the effectiveness of health provider continuing education and in-service training is computer-based training (CBT). Computer-driven, interactive video can portray simulated real-life clinical scenarios that students experience in a setting that threatens neither the student nor the patient. CBT can also give students a “clinical” context to enhance recall later in actual clinical practice settings. Computers also have the advantage over traditional training of allowing self-pacing and repetition by individual learners.
USAID has invested considerable resources in improving the quality of in-service training for health care providers and has supported the development of many online resources to strengthen the quality and effectiveness of training interventions, including those listed below.
Resources to Learn More: