Distance education with tutoring improves diarrhea case management in Guatemala

Objective. To evaluate the impact of distance education in diarrhea and cholera case management on the quality of physicians' and nurses' practice. Design. The pre-post panel, program and control group design used trained physician observers to measure if doctors and nurses complied with case management standards. Extended observations and client exit interviews were used to analyze audience bias and the validity of counseling measurements. Setting. Health care facilities in six districts of Guatemala. Ministries of Health in four Central American countries and the Institute of Nutrition for Central America and Panama implemented the course. Study participants. The study panel consisted of 66 course graduates (program group) and 66 doctors and nurses who were interested in taking the course where the course was not offered (control group). Results. The percentage of diarrhea cases assessed correctly and dehydration cases classified correctly increased by 25% more in the program group than in the control group, but post-course performance was still only -60% in the program group. Rehydration treatment did not improve. Counseling improved insignificantly. Client exit interviews suggested that indicators for counseling may need to be re-examined for validity. No audience effect on health worker practice was found. Completion rates were high. The program cost US$60 per enrollee. Conclusion. This is an effective, relatively low-cost program that substantially improved case management of diarrhea in Guatemala, in particular the quality of assessment and classification. However, many health workers who completed the course are still not performing to standard, so additional work is needed to resolve this problem.