Training that Sticks


This probably falls into the category of stuff everyone already knows, but it’s so important I wanted to mention it anyway.

Training is one of the most common interventions in international aid. It’s where we all start, when we think about problem solving. If the doctors/farmers/parliamentarians/journalists knew how to do their work better, everything would be just fine, right? But as we learn very quickly, training is one of the hardest things to get right. Here’s what I know.

Pre and post training knowledge tests are worthless. It doesn’t matter if people know more after your training. It matters if your trainees actually change the way they act after your training. The best solution I have found is competency-based training.

Competency-based training (CBT) means that you only teach people what they need to be able to do. Nothing extra. You don’t graduate them from the training until they can do it properly, in the context they need to do it in the future.

For a physician, then, if you are training on IUD insertion, you teach as much anatomy information as they need to do an IUD insertion. You then train them to do the insertion on life-like medical models and then you train them to do it on actual female volunteers. Finally, you observe them while they do insertions in patients in a clinical setting.

Notice what they are not doing: reading about IUD insertion or taking tests on their knowledge of female anatomy. Instead, they watch insertions being done, and they do them. Your physician officially completes the training and gets her certificate when she can insert an IUD correctly on her own in a clinical context.

CBT generally includes checklists that define the proper performance of whatever thing they’re teaching, for trainers to use as they observe trainees. If you want to use the best possible practice for your training, you don’t officially certify your trainees until they’ve been back at work for a while and you observe them using their new skills properly in their work practice.

Next, you need to make sure trainees are allowed to use their new skills. That means, at the very least, making sure that their supervisors understand and support the new approach and making sure that the new approach is legal. If you train teachers to use a new technique where students choose which topics to study, it won’t work if the principal won’t let them or the national curriculum requires certain topics during certain months. Training entire cohorts – everyone in one office, say – also helps support people to use their new skills.

Finally, if you want trainees to share their new skills, you have to put something official in place. It does not happen on its own. It doesn’t happen because people like being the most competent person among their peers and don’t necessarily want to share, and it doesn’t happen because just learning something new doesn’t make you a natural or comfortable trainer. You could, for example, require that all new trainees give a presentation to colleagues once they complete training (and you could plan for that by adding a session to the training itself for participants to develop and plan their presentation for colleagues). This probably won’t get those colleagues to change their behavior, but it will at least help everyone understand why one staff member is doing things differently.

Possibly the biggest challenge to getting impact from training is keeping your employees once they’re trained. Newly trained staff may leave through natural attrition, or because they are poached because of their updated skills. You can try positive incentives – pay raises, benefits like internet access or plots of land for kitchen gardens, but you can only provide so much in a resource-restricted context. Or you can try punitive methods – make people sign a contract to stay for a certain amount of time after training and pay a penalty of they don’t – but that can make people nervous about being trained.

I think the best solutions are long-term. You can train so many people that it makes up for natural attrition and floods the market to reduce demand. Or – this is my favorite solution – you can incorporate training into professional education. If every nurse learns patient counseling skills in nursing school, then you don’t need to come along and train them at all on the topic later.


Photo credit: US Army Africa.

Chosen because it’s competency based training in action. They’re not sitting there reading about house-to-house search.

Six things I was thinking about while on maternity leave:

1.       Does the success of cash transfers mean that poverty is a result of the capitalist system and instead of working for international development projects I should be an activist trying to change the global economy?

2.       Are we going to look back at 2011 as the year that climate change became obvious in US weather?

3.       Why is it so hard for people to understand breastfeeding? (I just had a woman at a convenience store tell me that she didn’t breastfeed because her milk didn’t come in because she didn’t drink much milk when she was pregnant. I was genuinely at a loss for words.)

4.       Behavior change efforts work best when we remove obstacles and help people do what they already want to do. Is it possible to frame all change programs that way? Or are we stuck always trying to change what people want to do?

5.       I agree with GiveWell’s conclusion that philanthropic money is better spent overseas than in the US (thus my career choice) but wow, the US is awfully bad off in some places.

6.       Premature babies are often born early because of difficult circumstances in the life of the mother: chaotic or abusive home life, poor nutrition, poor access to medical care. Then we sent these fragile babies home to the same situation that made them this way. It’s a vicious cycle.

Drinking Our Own ORS

(This is a reprint of a post I wrote for my Global Health Basics blog, which it turns out I have neither the time nor the technical prowess to maintain.)

In social media, they talk about eating your own dog food. In global health, I think the equivalent would be drinking our own Oral Rehydration Solution (ORS). We need to do a lot of that. It’s important to think about what we ask of people because it gives us a much clearer sense of why we get ignored. Here’s the starter list for how to drink your own ORS:

1. Drink an entire glass of ORS from a packet every time you get the runs, not the tastier homemade kind. Don’t take Imodium.

2. Boil and cool all your water before drinking it.

3. Never spend a single cent on a treatment or cure that hasn’t been proven to work. No vitamin C for a hangover, no Preparation H, no Neosporin on your cuts.

4. No antibiotics when they aren’t strictly necessary. That means nothing for your bronchitis or your child’s ear infection.

5. Use a condom every single time you have sex, even with your spouse, even if your spouse doesn’t want to.

6. Take your child to the doctor immediately if she is showing any of the IMCI warning signs, but don’t take her if she is less sick than that.

7. Breastfeed exclusively until six months, and continue breastfeeding until at least age 2. If you have to work, then express milk by hand into a jar and store it in a cool place. But never feed your child with a bottle. Use a cup and spoon.

8. Choose your food on the basis of what is cheapest and most nutritious, without regard for flavor or cultural tradition.

9. Don’t see the doctor you are most comfortable with; instead, see the doctor that your government recommends.

10. When caring for your sick child, don’t follow the advice of your mother or mother-in-law. Instead, follow advice from a government doctor you may only have met once.


(No antibiotics for her! photo credit: rabble)

Nutrition and Malnutrition


This one’s for Glenna.

There are lots of ways you can prevent or cure malnutrition. They come down to emergency feeding, supplementation, fortification, and changing food behaviors. Here’s a high-speed tour, in order of speed of impact and sexiness to donors.

Therapeutic foods come in two forms: powders that are mixed with clean water to become nutritional formulas, and ready-to-use therapeutic foods. Both are used as emergency measures, the tools of last resort to prevent death. You need to target them in a very specific way to use them well. Formulas are starting to be supplanted by the very trendy plumpy’nut, which can be used without a doctor’s attention once distributed. Some malnourished people are still so bad off that they need formula, though.

When you need therapeutic foods, something has already gone wrong. They are a patch for a broken system. A clear example of a downstream solution. Quick to get started, rapid results, no real long term impact. Very very sexy to donors, since feeding starving children is exactly the thing people think about when they picture aid work and projects get going fast.

Vitamin supplements don’t need to be heavily targeted, but you can’t just give them out to everyone. Different categories of people – children, pregnant women, and so on – need different nutritional supplements. Not a ton of supervision is needed, but some. In addition to targeting, someone has to physically give them out. Supplements need a health system, or at least a logistical system, behind them. Somewhat exciting for donors, since programs gear up fast and little children line up adorably to get their vitamins.

Food fortification doesn’t need a logistical system or medical support. If you get iron and folic acid into the flour, iodine into the salt, and vitamin E into the oil, you can improve the nutritional status of an entire population. But you end up supplementing a whole lot of people who don’t need it. It’s effective, but it’s not efficient. You also need a government capable of enforcing fortification, so it’s an upstream solution. And we’re starting to see some evidence that some kinds of fortification, like folic acid, can increase some kinds of cancer, so they are not an unqualified good. Fortification is boring for donors. They details and politics of fortification are honestly pretty boring for nutrition experts, let alone people trying to decide where to give their twenty bucks or overworked government types.

Lastly, changing food behavior involves teaching people how to eat in a way that meets their nutritional needs. The classic examples are not selling home-grown vegetables and using the money to buy processed foods, and increasing the consumption of legumes, especially in combination with leafy greens. So many things affect individual eating behavior that this is an upstream and a downstream solution. It’s about what is available to eat, and what people choose from that. Changing nutrition behaviors is very, very hard. It takes a long time and shows its impact slowly. It’s downright repulsive to donors, because it reminds everyone of all the vegetables they ought to be eating themselves.


Photo credit: mashnicaragua

Chosen for reasons I hope are obvious.

Things I believe in #13: Giving your team hats and t-shirts

When I sat down to expand on this, I realized what I really meant was – make your staff into a team. Treat them as competent professionals working together for a common goal. Giving them swag is one way to do that; putting everyone in the same t-shirt makes them look physically like equals. It makes them feel commonality with headquarters, and with the other offices in the country and around the world.

Every single paid staff member and volunteer should know where your organization is based, who funds it, and the general outline of its national programs. Paid staff members should know more. They should know the basic details of all your country projects, not just the ones they work for. If you have behavior change messages, every single employee should know them. This includes your drivers, your cleaners, your gardeners, and your tea lady (and if your behavior change messages are too complex for the tea lady, you’ve got problems).

Your people should know what it means to work for you, and they should be proud of it. They should know your general country budget, and your global budget. They should know where the money comes from – DFID, USAID, private donors, or whoever. They should know your organization’s global mission.

Now you’re wondering, why bother with this level of staff integration? Because everybody wins when you make your staff into a team. A high-functioning team generates a synergy of local and expat knowledge that takes your projects to a new level. Your organization benefits by running more effective, more efficient programs. Your host country benefits because the quality of your work is better.

It takes more than a weekly staff meeting to make this kind of team effort happen. Personally, I like posters and diagrams in common areas explaining program components. I like using your whole team as your first focus group for behavior change materials. I like having your country director give periodic updates on budgets and progress toward program goals. I like giving your team free lunches and doing presentations on different program components. I like having people from different teams share drivers and office space.

on research and donor funding

This nice summary of BDI logic models does two things. It 1) gives you an overview of a model for behavior change that actually takes into account the complexity of human decision-making and 2) tells you how to market it to potential donors. It’s very savvy, and it makes me kind of sad. I see useful public health research go unused all the time because it’s too complicated for non-experts, and donors are rarely experts.

Two on Tuesday – Systems Failure

Two on Tuesday is a new feature where I find a couple examples of a phenomenon or issue that I find interesting, and try to learn something useful from them.

I recently ran into two examples of systems failure, both of which offer useful lessons in organizational function.

Example #1 – New Orleans. A community program to identify and report blighted houses gets canceled. Why? Because they never connected the web-based reporting system to the team which investigated. It would have been very simple to synchronize blight investigations with the complaints logged on the web, but it simply never happened. My guess is that the web site was designed by an IT department who had little or no contact with the people who actually did investigations.

Lesson learned: Don’t create a communications interface if you have no way of using the information you get from it.

Example #2 – the FAA. Safety investigator Mark Lund discovered that Northwest airlines mechanics were so incompetent they couldn’t close a cabin door or test an engine. When he tries to ground the planes, the FAA retaliates against him, not the airline. Why? Because the FAA was invested in its role as an agency that keeps American aviation flying, more its role as safety watchdog.

Lesson learned: You can’t be all things to all people. Give your investigators the independence they need to do their jobs right.

I spend a lot of time thinking about systems, and setting them up for success. Nearly as much as time as I spend thinking about behavior change. It’s easy to blame individual people when things go wrong, but we should design important process to help people make the right choices, and to catch errors. No system should ever depend on everybody doing their job right, because human beings just aren’t consistent enough.