A clinical training unit for diarrhoea and acute respiratory infections: an intervention for primary health care physicians in Mexico

In Tlaxcala State, Mexico, we determined that 80% of children who died from diarrhoea or acute respiratory infections (ARI) received medical care befo re death; in more than 70% of the cases this care was provided by a private physician. Several strategies have been developed to improve physicians' p rimary health care practices but private practitioners have only rarely bee n included. The objective of the present study was to evaluate the impact o f in-service training on the case management of diarrhoea and ARI among und er-5-year-olds provided by private and public primary physicians. The train ing consisted of a five-day course of in-service practice during which phys icians diagnosed and treated sick children attending a centre and conducted clinical discussions of cases under guidance. Each training course was lim ited to six physicians. Clinical performance was evaluated by observation b efore and after the courses. The evaluation of diarrhoea case management co vered assessment of dehydration, hydration therapy, prescription of antimic robial and other drugs, advice on diet, and counselling for mothers; that o f ARI case management covered diagnosis, decisions on antimicrobial therapy , use of symptomatic drugs, and counselling for mothers. In general the per formance of public physicians both before and after the intervention was be tter than that of private doctors. Most aspects of the case management of c hildren with diarrhoea improved among both groups of physicians after the c ourse; the proportion of private physicians who had five or six correct ele ments out of six increased from 14% to 37%; for public physicians the corre sponding increase was from 53% to 73%. In ARI case management, decisions ta ken on antimicrobial therapy and symptomatic drug use improved in both grou ps; the proportion of private physicians with at least three correct elemen ts out of four increased from 13% to 42%, while among public doctors the co rresponding increase was from 43% to 78%. Hands-on training courses thus se emed to be effective in improving the practice of physicians in both the pr ivate and public sectors.