TTT(TOT)프로그램의 가장 효과적인 방법: A Systematic Review (J Contin Educ Health Prof. 2012)

TTT(TOT)프로그램의 가장 효과적인 방법: A Systematic Review (J Contin Educ Health Prof. 2012)

The Most Effective Way of Delivering a Train-the-Trainers Program: A Systematic Review

JENNIFER PEARCE, BSC; MALA K. MANN, BECCERTLIS, MIINFSC, MCLIP; CARYL JONES, BSC, MSC;

SUSANNE VAN BUSCHBACH, BSC, MSC; MIRANDA OLFF, BSC, MSC, PHD; JONATHAN I. BISSON, BM, FRCPSYCH,

DIP CLIN PSYCHOTHERAPY DM

Introduction

보건 및 사회 복지 전문가에게 정보를 보급하는 데 있어 passive, didactic 교육 전략보다 효과적이고 신속한 / reminder 시스템의 형태를 포함하는 multifaceted, interactive  개입이있을 수 있다는 증거가있는 것으로 보인다 .1-6 그러나, 이러한 증거가 증가하고 있음에도 불구하고, 방법론 및 보고 결함으로 인해 그러한 정보를 가장 효과적으로 전파하는 방법에 대한 기존 문헌에서 확고한 결론을 도출 할 수 없으므로 결론을 내리기가 어렵습니다 .2-3

There appears to be some evidence that multifaceted, interactive interventions, possibly with the inclusion of some form of prompt/reminder system are more effective than passive, di- dactic education strategies in disseminating information to health and social care professionals.1–6 However, despite this growing evidence, conclusions are made difficult because it has been suggested that no firm conclusions can be drawn from the existing literature on how best to disseminate such information due to methodological and reporting flaws.2–3

경험적으로 보았을 때 도움이 되는 것으로 보이는 다양한 interactive and multifaceted 기술을 결합 할 수 있기 때문에, TTT (train-of-trainers) 교육 모델이 효과적이고 비용 효율적인 효과적인 방법으로 제안되었습니다 .1-6 Train-the - 트레이너 (Trainer) 란 특정 분야의 개인이 특정 주제에 대한 교육을 받고, 다른 사람들을 훈련, 감독 및 감독하는 방법에 대한 교육을받는 프로그램을 말한다.
A Train- the-Trainers (TTT) educational model was proposed as a po- tentially effective and cost-efficient way of doing this, as it could combine the various interactive and multifaceted techniques that have received some empirical support.1–6 Train-the-Trainer refers to a programor a course where indi- viduals in a specific field receive training in a given subject and instruction on howto train, monitor, and supervise other individuals in the approach.8–9

 

방법

Method

The methods used in this review followed the recommended methodology for conducting systematic reviews.10

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Information Sources

The databases Applied Social Sciences Index and Abstracts (ASSIA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Med- ica Database (EMBASE), Education Resources Information Center (ERIC), Health Management Information Consor- tium (HMIC), MEDLARS Online (MEDLINE), Medline in Process, System for Information on Grey Literature in Europe (OpenSigle), Psychological Information Database (Psycinfo), Scopus, Social Care Online, Social Services Ab- stracts, Sociological Abstracts, Web of Knowledge, and Pub- lished International Literature on Traumatic Stress (PILOTS) were searched from inception through June 15, 2011.

포함 기준

Inclusion Criteria

Intervention. The intervention had to be based on a TTT model; that is, the participants being trained in the inter- vention must have to go on to train others in the specified topic/guidance following their training. Topics of interest in- cluded any health or social care field (eg, HIV/AIDS, breast- feeding, mental health, counseling). There were no restric- tions on duration, format, or content of the TTT model.

Target Population. The participants inthe TTTprogram must have been qualified health and social care professionals who, after receiving training, were expected to be capable of deliv- ering training to other health care professionals. Specifically, we were interested in the health and social care professionals who attended the TTT programs, including nurses, psychol- ogists, social workers, and the like.

Study Design. Randomized controlled trials (RCTs), well- designed quasi-experimental studies, controlled before-and- after studies (CBAs), and interrupted time series analyses (ITS) were included, subject to the presence of a control group. There also must have been a follow-up outcomes measure administered more than 1 week after the intervention was delivered (eg, participants’ clinical behavior 3 months after the training program).

Outcome. The outcomes must have been related to the effec- tiveness of the training program and include some objective measure of change. Outcomes could relate to the primary re- cipients of the TTT intervention or the secondary recipients (the health and social care professionals who subsequently re- ceived training from the primary recipients). For either group of recipients, outcomes could be at the level of knowledge, clinical behavior, or patient outcomes.11 It was agreed a pri- ori that outcomes should include objective measures relating to participants or patients/clients as either would be likely to represent a valid measure for assessing the effectiveness of a TTT program.

Publication. Published and unpublished studies were eligi- ble for inclusion.

배제 기준

Exclusion Criteria

Study Design. Studies relying on anecdotal evidence derived from individual opinions and studies without control groups were excluded.

Language. Non-English-language studies were excluded due to financial constraints.

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Data Extraction

The details extracted from the studies were study design; population characteristics; characteristics of the intervention, including the content, format, setting and duration; a de- scription of the primary outcome measure; description of the training methods used; details on participants’ recruitment; who delivered the training; what course materials were used; what implementation issues there were; and the effective- ness of the intervention.

자료 병합

Data Synthesis

The primary outcome measure was the effectiveness of the training intervention, either through knowledge tests, clini- cal behavior, or patient reports.

편향 위험

Risk of Bias

The risk of bias for all included studies was assessed using the 6 specific domain-based evaluation criteria set out in the Cochrane risk of bias form.10 These were

• sequence genera- tion,

• allocation concealment,

• blinding,

• incomplete outcome data,

• selective outcome reporting, and

• other sources of bias.

Two reviewers independently assessed each study for risk of bias. Any conflicts were discussed with a third reviewer.

Results

Study Selection

Data Synthesis

Study Characteristics

Study Design. Three study designs were employed;

• 8 ran- domized controlled trials,8,13–20

• 6 controlled before-and- after studies,21–26 and

• 4 controlled clinical trials.9,27–29

 

The topic, content, materials, setting, duration, and primary out- come measures of the TTT programs varied greatly, which made direct comparisons problematic (for full details see TABLE 1 and the Supporting Information for this article).

Methods of Training. The training methods em- ployed varied considerably:

• 7 reported including scenarios,8–9,19,23,26–27,29

• 4 didactic case studies and presentations,19,22,24,27

• 2 video presentations,24,29

• 3 PowerPoint slides discussions,9,19,24–25,29 ,9,23,28 5

• 9 group components,8–9,13–15,19,22,26–27

• 7 practical interactive exercises,8,13–14,21,26–28

• 5 demonstrations and

• 4 role- plays,19,24,27,29

• 1 motivational and attitudinal change elements,21

• 1 individual feedback on strengths and weaknesses,22

• 1 problem-based learning,16

• 5 preparation to deliver future training workshops,19–20,23,28–29 and

• 1 questions-and-general-comments session.24

Effectiveness of Training

Training Versus No Training. All studies evaluated a training group versus a nonintervention (control) group.

Outcome Measures

Clinical Behavior. Eight of the studies used measures ofclinical behavior to assess the effectiveness of the TTT program

Knowledge Tests. Six studies assessed effectiveness through knowledge tests

Patient Outcomes. Four studies measured patient out- comes in order to assess the effectiveness of the TTT program,

Risk of Bias Within Studies

연구 방법론의 등급은 포함 된 모든 연구에 대한 편견의 위험을 제안했습니다. 18 개의 논문 중 2 개는 편견의 위험이 높다고 판단되었다 .22,25 왜냐하면 통제 집단과 중재 집단에 대한 할당이 무작위화된 것이 아니기 때문이다. Byrne 등 22)의 연구에서 두 그룹의 전문직 간에는 상당한 차이가 있었다 (전문 훈련을받은 그룹의 간호사 37 %는 초보 훈련 그룹의 78 %와 비교). 이것은 잠재적으로 TTT 중재의 훈련 및 전달에 영향을 줄 수 있습니다. 1 개의 study15 만 프로토콜을 출판했기 때문에 편향의 위험이 낮은 것으로 판단 된 연구는 없습니다. 이것은 결과가 선택적으로 보고되었는지 여부를 판단 할 수 없다는 것을 의미했습니다. 따라서 우리의 결론은 포함 된 연구의 편견에 의해 제한됩니다.

Ratings of the studies’ methodologies suggested risk of bias for all included studies. Two of the 18 papers were judged as having a high risk of bias22,25 because the allocation to con- trol and intervention groups was not randomized. In Byrne et al’s study,22 there was a significant difference between the 2 groups’ professions (37% nurses in the expert trained group compared with 78%in the novice trained group). This could potentially have affected the training and delivery of the TTT intervention. No studies were judged to have a low risk of bias, primarily because only 1 study15 had published a protocol. This meant that it was not possible to judge whether outcomes had been selectively reported. Our conclusions are, therefore, limited by the bias of included studies.

Discussion

이 리뷰에는 18 개의 논문이 포함되어 있었고, 상당한 이질성으로 비교에 어려움이 있었음에도 불구하고 TTT 프로그램에 대한 지원은 건강 및 social care 전문가에게 지식과 정보를 보급하기위한 효과적인 방법으로 제공되었습니다. 18 개의 연구 중 13 개는 TTT 프로그램이 임상 행동을 개선하는 데 크게 도움이되었으며, 8,15-16,19-20,26은 지식을 22,25,28-29로 증가 시키거나 더 나은 환자 결과를 가져옴을 보여주었습니다. 또 다른 3 개의 연구가 잠재적 효과를 보였고, 9,18,24 1 시험 13-14 효과가 없었고, CD-ROM 교육이 TTT 교육보다 효과적이라는 것을 발견했다 .17) 논문 및 체계적인 검토 저자 논문에 포함 된 다른 정보의 해석은 각 연구의 효과 강도를 결정하는 데 사용되었습니다.

Eighteen papers were included in this review and, despite significant heterogeneity compromising comparison, pro- vided support for TTT programs as an effective way to disseminate knowledge and information to health and so- cial care professionals. Thirteen of the 18 studies showed that TTT programs significantly helped to improve clini- cal behavior,8,15–16,19–20,26 increase knowledge,22,25,28–29 or resulted in better patient outcomes.21,23,27 Another 3 studies showed a possible effect,9,18,24 1 study13–14 no effect, and an- other found that CD-ROM training was more effective than TTT training.17 Data contained within the papers and the systematic review authors’ interpretation of other informa- tion contained within the papers were used to determine the strength of effect of each study.

긍정적 인 연구 중 11 개는 interactive components 를 사용하여 교육을 제공했습니다. 8,15,19,21-23,25-29이 분야의 이전 연구를 지지하며, 이는 대화식 교육 방법이 수동형, Didactic 스타일 교육보다 더 효과적임을 시사한다.1-6 효과에 대한 결정적인 결론을 내릴 수없는 두 건의 연구와 TTT 프로그램이 아무 효과가 없다는 연구가 있었다 .13-14 또한 교육을 제공하기 위해 상호 작용 요소를 사용했다. 이것은 상호작용interactivity만으로는 교육 프로그램을 제공 할 때 긍정적 인 결과를 얻는 데 필수적인 변수가 아님을 나타냅니다.

Eleven of the positive studies used interactive compo- nents to deliver the training.8,15,19,21–23,25–29 This supports previous research in the field, which suggests that interactive training methods can be more effective than passive, didac- tic style training.1–6 Two of the studies where no definitive conclusions of effectiveness could be made9,24 and the study that found the TTT program to have no effect13–14 also used interactive components to deliver the training. This suggests that interactivity alone is not necessarily the key variable in achieving a positive outcome when delivering a training program.

포함 된 연구의 대다수는 3 일이 넘는 기간 동안 9,15-16,18,20-23,25 이상의 기간 동안 훈련을 전달했으나, 지식의 증가 또는 임상 적 행동과 환자 결과의 개선에 도움되는 수준을 보면, 3일 또는 그 이내에 훈련을 실시한 연구도 비슷하게 효과적이었습니다 .8,19,26-28
The majority of the included studies delivered the train- ing over more than a 3-day period,9,15–16,18,20–23,25 but the studies that delivered the training in 3 days or less were simi- larly effective in increasing knowledge or improving clinical behavior and patient outcomes.8,19,26–28

 

TTT 프로그램에 수반되는 학습 자료를 포함시키는 효과는 분명하지 않다. 유인물, 안내서 또는 정보 폴더를 제공하는 모든 연구가 효과적이었습니다 .16,19-20,23,26,28-29 이는 TTT 프로그램을 학습 자료와 결합하면 TTT의 효과가 향상 될 수 있음을 나타냅니다. 이 개념은 Tziraki et al19 및 Martino et al's20 연구에서 발견 된 TTT 프로그램과 메뉴얼을 제공한 그룹이 메뉴얼만 제공하거나 또는 자율학습을 한 그룹보다 효과적이라는 결과를 뒷받침합니다. 그러나 다른 연구들도 이러한 발견을 뒷받침 해주었습니다 .30-31 그러나 TTT 프로그램이 효과가있는 것으로 밝혀진 여러 연구는 동반 학습 자료에 대한 정보를 제공하지 않았다. 또한 추가 학습 자료를 제공하는 TTT 프로그램과 그렇지 않은 TTT 프로그램에 대한 연구는 없으므로 결정적인 결론을 내릴 수 없습니다.

The effect of including accompanying learning materi- als in TTT programs is unclear. All the studies that pro- vided handouts, manuals, or folders of information were effective.16,19–20,23,26,28–29 This suggests that combining the TTT program with learning materials may improve the ef- fect of the TTT program. This notion is also supported by the findings in Tziraki et al19 and Martino et al’s20 studies, which showed that the TTT program and manual group was more ef- fective than a manual only or self-study group. Other studies have supported this finding.30–31 However, a number of the included studies in which the TTT program was found to be effective did not provide information on accompanying learn- ing materials. Additionally, no studies have compared a TTT program with additional learning materials to a TTT program without, allowing no definitive conclusions to be made.

이 검토에는 8 건의 무작위 대조 연구 (RCT)가 포함되었다. RCT 방법론을 사용한 두 연구 13-14,17은 아무 효과가 없거나 대안 교육 방법이 TTT 프로그램보다 효과적이라는 것을 발견했습니다. 이것은 훈련 전문가의 TTT 프로그램에 대한 우월성을 보여주는 5 개의 다른 RCT 8,15-16,19-20에 의해 균형을 이룹니다.

Eight randomized controlled trials (RCTs) were in- cluded in this review. Two studies that used an RCT methodology13–14,17 found no effect or that an alternative training method was more effective than a TTT program. This is balanced by five other RCTs,8,15–16,19–20 which showed superiority for a TTT program in training professionals.

 

이 연구에서 포함 된 대부분의 연구에서 TTT 프로그램이 효과적이라는 것을 알았지 만 CD-ROM 교육 방법으로 TTT 개입을 비교 한 1 개의 연구에서 후자가 참가자의 지식을 향상시키는 데 더 효과적이라는 사실이 밝혀졌습니다. Martino와 동료들의 study20은 또한 expert-led training group 이 TTT 훈련 그룹만큼 효과적이라는 것을 발견했다 .32-33 컴퓨터 보조 훈련의 지원은 다른 연구에서도 발견되었다. 이 연구는 TTT 프로그램 접근법이 건강 및 사회 전문가를 효과적으로 훈련시키는 데 사용할 수있는 유일한 훈련 방법이 아니라는 것을 제시합니다. 어떤 방법을 언제 사용해야하는지 명확히하기 위해서는 더 많은 연구가 필요합니다.

Although the majority of the included studies in this re- view found that a TTT program was effective, 1 study com- paring a TTT intervention with a CD-ROM training method found that the latter was more effective in improving partic- ipants’ knowledge.17 Support for the use of computer-aided training has been found in other studies.32–33 Martino and colleagues’ study20 also found that an expert-led training group was as effective as the TTT training group. These studies suggest that a TTT program approach is not the only training method that can be used to effectively train health and social professionals. Further research is needed to clarify which methods should be employed and when.

 

 

이 검토는 TTT 프로그램의 효과에 대한 체계적인 첫 번째 검토이므로이 분야의 지식 기반에 대한 실질적인 기여를 보여준다. 우리는 이 분야에서 연구의 양과 질을 결정하기 위해이 리뷰를 시작하기 전에 Cochrane 방법 10을 사용하여 범위 지정 검색을 수행했습니다. 이것은 우리 리뷰의 목적과 디자인을 구체화하고 알리는 데 도움이되었습니다.

This review is the first systematic review of the effective- ness of TTT programs and therefore represents a substantial contribution to the knowledge base in this area. We con- ducted a scoping search using the Cochrane method10 before commencing this review to determine the quantity and qual- ity of research in this field. This helped to refine and inform the aims and design of our review.

이 리뷰와 이전 문헌의 증거 1-6은 서로 다른 임상 영역에서 일하는 다양한 문화권의 건강 및 사회 복지 전문가에게 가이드 라인 및 커리큘럼을 보급하고 구현하기 위해 interactive, multifaceted TTT 프로그램의 사용을 지지합니다. 이전 문헌은 전문가를 양성하기 위해 "혼합 학습"접근법을 사용함으로써 얻을 수있는 이점을 강조했다 .4-44 혼합 학습 접근법은 "서로를 보완하고 학습과 응용을 촉진하도록 설계된 다중 전달 매체를 결합하여" "37 상호작용적interactive 구성 요소와 학습 자료를 포함한 기술의 조합을 혼합하여 보건 및 사회 복지 전문가를위한 가장 효과적인 교육 과정을 만들고, 전통적이고 교훈적인 스타일의 교육은 blended approach의 일부로만 사용되어야 한다고 결론 내릴 수 있습니다. 그러나 가장 효과적인 TTT 프로그램을 개발하기 위해 사용해야하는 기술의 정확한 균형과 혼합을 식별하는 것은 불가능합니다.
The evidence from this review and previous literature1–6 provides support for the use of interactive, multifaceted TTT programs to disseminate and implement guidelines and cur- ricula to health and social care professionals from diverse cultures working in different clinical areas. Previous litera- ture has highlighted the benefits of using a “blended learning” approach to train professionals.34–36 A blended learning ap- proach is described as combining “multiple delivery media that are designed to complement each other and promote learning and application-learned behaviour.”37 It can be con- cluded that a combination of techniques, including interac- tive components and learning materials, should be blended to create the most effective training course for health and social care professionals and that traditional, didactic-style training should only be used as part of a blended learning approach. It is not possible, however, to identify the exact balance and blend of techniques that should be used in order to develop the most effective TTT program.

이 review8-9,15의 세 가지 연구는 TTT 모델의 잠재적 인 장기적 문제를 확인했다. 교육을 받은 후 높은 직원 교체율과 직원 보유로 인해 교육 프로그램을 지속적으로 구현하기가 어려웠다는 사실을 발견했습니다. TTT 프로그램을 개발할 때 장기적인 지속 가능성과 직원 헌신을 고려할 필요가 있습니다.

Three studies in this review8–9,15 identified a potential long-term problem with the TTT model. They found that it was often difficult to ensure the continuing implementation of the training programs due to high staff turnover and retention of staff after they had been trained. Long-term sustainability and staff commitment need to be considered when developing TTT programs.

 

프로그램 개발자는 구체적인 목표 청취 및 설정에 맞는 접근 방식을 최적화하기 위해 교육 프로그램을 개발할 때 전달 방법, 프로그램 내용 및 직원 충원 및 유지 문제를 신중하게 고려해야합니다. CD-ROM 교육 방법이 TTT 프로그램보다 효과적이라는 연구 결과는 임상 행동, 지식 및 환자 결과를 개선하기위한 다른 비용 효과적 인 교육 방법이있을 수 있음을 시사합니다. 프로그램 개발자는 훈련 프로그램을 설계 할 때 롤 플레이 (role-play) 및 그룹 토의 (group discussion)와 같은 대면 훈련 기술을 통합하는 명백한 유틸리티와 함께 ​​이것을 고려해야합니다.

Program developers should give careful consideration to delivery method, program content, and issues of staff com- mitment and retention when developing training programs in order to optimize the approach to fit the specific target audi- ence and setting. The finding that a CD-ROM training method is more effective than a TTT program17 in 1 study suggests that there may be other, perhaps more cost-efficient train- ing methods, to improve clinical behavior, knowledge and patient outcomes. Program developers need to consider this alongside the apparent utility of incorporating face-to-face training techniques, such as role-play and group discussions, when designing training programs.

현재 이용 가능한 증거의 한계에도 불구하고,이 검토는 TTT 프로그램이 건강 및 사회 복지 전문가에게 정보를 효과적으로 유포 할 수있는 가능성이 있음을 보여주었습니다. 다양한 기술과 자료를 결합한combining different techniques and materials 혼합 학습 방법을 사용하면 최상의 결과를 얻을 수 있습니다. 기술의 최상의 "혼합"을 결정하고 참여자 및 환자 / 고객이 직면하는 결과 측정에 미치는 영향에 대한 추가 연구가 필요합니다. TTT 모델에 사용 된 다양한 기술 조합을 검사하는 무작위 통제 시험은 가장 효과적인 효과적인 혼합을보다 잘 판단하는 데 도움이됩니다. 또한 미래 작업은 상호 작용을보다 자세히 고려해야합니다 .1,2,4

Despite the limitations of the currently available evidence, this review has shown that TTT programs have the potential to effectively disseminate information to health and social care professionals. It appears that using a blended learning approach, combining different techniques and materials, is likely to achieve the best results. Further research is needed to determine the best “blend” of techniques and howthey impact on participant and patient/client facing outcome measures. A randomized controlled trial that examines different combinations of techniques used in TTT models would help to better determine themost effective blend. Additionally, futurework should consider interactivity in more detail.1,2,4 

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J Contin Educ Health Prof. 2012 Summer;32(3):215-226.

The most effective way of delivering a train-the-trainers program: a systematic review.

Pearce J1, Mann MK, Jones C, van Buschbach S, Olff M, Bisson JI.

Author information

• 1Department of Psychological Medicine, Cardiff University, Wales.

Abstract

INTRODUCTION:

Previous literature has shown that multifaceted, interactive interventions may be the most effective way to train health and social care professionals. A Train-the-Trainer (TTT) model could incorporate all these components. We conducted a systematicreview to determine the overall effectiveness and optimal delivery of TTT programs.

METHODS:

We searched 15 databases. Reference lists and online resources were also screened. Studies with an objective follow-up measure collected over 1 week after the intervention were included. The intervention had to be based on a TTT model for health and social care professionals.

RESULTS:

Eighteen studies met the inclusion criteria. TTT interventions varied greatly, ranging from didactic presentations to group discussions and role-plays. The heterogeneity of the studies and limited data prevented meta-analysis. A narrative review found that the TTT programs in 13 studies helped to increase knowledge, improve clinical behavior, or produce better patient outcomes. One study showed no effect. Three studies showed possible effect and one study showed that a CD-ROM training method was more effective than a TTT training method in improving participants' knowledge. Ratings of the studies' methodologies suggested moderate risk of bias, which limits interpretation of the results.

DISCUSSION:

There is evidence that using a blended learning approach to deliver TTT programs--combining different techniques such as interactive, multifaceted methods and accompanying learning materials--can help to effectively disseminate and implement guidelines and curricula to health and social care professionals. However, further research is needed to determine the optimum "blend" of techniques.

PMID:

 

23173243

[PubMed - indexed for MEDLINE]