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Wednesday, February 18, 2015

"Know-do" gap in Indian Rural Healthcare

Diarrhoea and pneumonia are major childhood killers. The diarrhoea management has a large "know-do"gap in certain parts of India.

The study was conducted in 2012 (June - September) by Duke University, Durham using vignette interviews and unannounced standardised patients (SPs) and has been published only in February 2015 (available online in JAMA Pediatrics)
Diarrhoea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhoea vignettes, 71.9% offered them to SPs (P < .001) (1)
For childhood diarrhoea, Oral Rehydration Therapy and not antibiotics is the right treatment.

In this study, antibiotics and other not-indicated drugs were prescribed by all providers. Even those who provided the Oral Rehydration therapy included antibiotics in their prescriptions. The scenario such that none of the providers (medical degree holders, traditional medicine practitioners or unqualified persons???(data unavailable clearly) provided the right treatment.

A large segment of rural sector in poor-resource countries like India are catered by such providers. Antibiotic abuse, self medications, poor antibiotic stewardship, poor healthcare infrastructure in the rural areas and poor awareness among the people all could be contributory to this aberrant situation.

A similar study published earlier conducted in Rural Madhya Pradesh had similar findings.(2)

The situations reveals a shocking truth that - "Knowing" does not mean "doing" always! Healthcare is plagued by many such know-do gaps commonly in the areas of antibiotic prescriptions and hand washing.

Healthcare providers continue to prescribe antibiotics in cases where they are not indicated even while their training starting from their 2nd year microbiology classes have repeatedly revealed that inappropriate antibiotic use can result in antimicrobial resistance.

There is a poor compliance with hand washing even in operation theatre settings. Proper hand washing compliance stands at a low 40-50% even in large hospitals in urban settings.
  • Why this "know-do" gap ?
  • What prevents one from "practicing" what one has learnt ?
  • What causes one to deviate in a major way from the accepted practices ?
The answers to these questions may reveal us to the root cause and help us solve the issue.

  1. Mohanan M, Vera-Hernández M, Das V, et al. The Know-Do Gap in Quality of Health Care for Childhood Diarrhea and Pneumonia in Rural India. JAMA Pediatr. Published online February 16, 2015. doi:10.1001/jamapediatrics.2014.3445. (Link)
  2. Das J, Holla A, Das V, Mohanan M, Tabak D, Chan B. In Urban And Rural India, A Standardized Patient Study Showed Low Levels Of Provider Training And Huge Quality Gaps. Health affairs (Project Hope) 2012;31(12):2774-2784. doi:10.1377/hlthaff.2011.1356. (HTML Full Text) (PDF Full text)