Voir page 943 le resume en franfais. En la pagina 944 figura un resumen en espanol.
Several studies in developing countries have reported underuse of oral rehydration salts as well as overuse of antibiotics, symptomatic drugs and laboratory examinations by primary health care physicians when treating children with diarrhoea and acute respiratory infections (ARI) (1-5). These incorrect practices represent a risk for children's recovery and wellbeing, and raise the cost of medical attention for both families and health institutions. In Mexico, as in other countries, many deaths from diarrhoea and ARI could be prevented if appropriate medical care were provided. We found that more than 60% of children who died from diarrhoea or ARI did so at home, and that over 80% of them had received medical care by primary health care physicians, mostly during the 24 hours before death (6, 7).
Several strategies have been developed to improve physicians' primary care practices (8-11). Our group has developed an educational strategy based on the active participation of physicians in workshops. Following discussions on good health practice, peer review committees were formed to build consensus and a commitment to adopting better diagnosis and treatment practices (12, 13). About half the physicians attending the workshops changed their clinical practices (14).
The above activities focused exclusively on physicians working for public institutions. However, private physicians are equally important providers of primary care. An analysis of verbal autopsies in areas of high diarrhoea mortality in 1990-93 showed that 70% of children who died had received medical care and that 54% of these children had been seen by a private physician (15). Private physicians are clearly an important target group for intervention.
In most medical care systems in developed countries, physicians receive the bulk of their training in teaching hospitals, i.e. there is a heavy bias towards secondary or tertiary care. Good training facilities are only seldom available to teach physicians how to deal with patients at the primary care level. WHO has recommended the development of such facilities for the provision of in-service training (16). On this basis we established a training unit for diarrhoea and AR/ in the State of Tlaxcala, which has the highest infant mortality rate from diarrhoea and ARI in Mexico (17). Both public and private primary care physicians were invited to accept in-service training in the case management of children aged under 5 years who had diarrhoea or ARI. The present study evaluates the impact of the training on the physicians.
The study was carried out in the State of Tlaxcala between January 1993 and April 1994. Tlaxcala, about 150 km east of Mexico City, is the smallest state in Mexico. At the time of the study the population was 759 000, of whom 14% were children aged under 5 years. The infant mortality rates from diarrhoea and ARI were 5 and 9 per 1000 live births, respectively, the highest in the country. For children aged 1-4 years, the ARI and diarrhoea mortality rates were 46 and 52 per 100 000, respectively; ARI and diarrhoea were the two commonest causes of death in this age group (17). Tlaxcala has 42 municipalities grouped into 17 local health authorities. The present study included five of these authorities, all under the direction of the Tlaxcala Ministry of Health General Hospital in the capital city. This hospital, a second-level facility, is the referral centre for primary care units in the area.
All private physicians practising in the study area who were providing care for children under 5 years of age and who did not work in public institutions were eligible for the study. To identify private physicians, we carried out a census in collaboration with the state's Ministry of Health. …