Medics in rural India unaware of correct treatment for childhood infections

Last Updated: 2015-02-17

By Vidya Shankar MD

NEW YORK (Reuters Health) - A vast majority of healthcare providers in Bihar province of northern India interviewed for a recent study were unaware of the appropriate treatments for diarrhea and pneumonia, the biggest contributors to child mortality.

Even the few who were aware failed to prescribe the correct treatment, according to the results of a new study published online February 16 in JAMA Pediatrics.

Many were not aware of use of oral rehydration solution (ORS), but prescribed antibiotics for diarrhea while using steroids with allergy medicines for pneumonia, the researchers report.

So-called "know-do" gaps result when healthcare practitioners do not put into practice the knowledge they possess.

"Our evidence on the gap between knowledge and practice suggests that training alone will be insufficient. We need to understand what incentives cause providers to diverge from proper diagnosis and treatment," lead author Dr. Manoj Mohanan, from Duke University, Durham, North Carolina, said by email to Reuters Health.

Diarrhea and pneumonia account for 2 million deaths among children and 24% of deaths among children aged 1-4 years worldwide. In rural Bihar healthcare is predominantly provided by untrained personnel with limited knowledge and "even lower levels of observed performance," the researchers point out.

Dr. Mohanan and his team interviewed 340 healthcare providers in Bihar to ascertain their knowledge and quality of care of childhood diarrhea and pneumonia. Knowledge of the two diseases was assessed by their response to vignettes in the form of hypothetical cases presented to them by trained interviewers.

For assessment of the quality of care, they used a standardized patient method where a person is trained to act as a patient and made unannounced visits to the practitioner. In this case, it was the father unaccompanied by children who approached the practitioner for treatment of their ill child. They clarified that this practice of unaccompanied parents approaching providers on behalf of the child is common in rural India.

The researchers found that 272 (80%) of practitioners had no formal medical training. In the knowledge assessment vignette interview, on an average they asked less than three questions for diarrhea and just one question for pneumonia before making a treatment plan.

Nearly three-fourths of the practitioners diagnosed diarrhea (74.5%), but fewer than a third (32.9%) asked questions that would assess the severity of diarrhea - urine output, fluid intake or level of activity.

A vast majority (86.8%) did not inquire about bloody stools that would distinguish diarrhea from dysentery. Only 3.5% recommended ORS/ORS zinc, the gold standard treatments, while 20.9% prescribed no ORS at all but only antibiotics or steroids.

Though a majority (59%) of practitioners could diagnose pneumonia from the history provided, fewer than a quarter asked about rapid breathing, an important sign of respiratory distress.

Appropriate antibiotics were recommended by fewer than a tenth of the practitioners (8.8%), while 43.8% prescribed antibiotics in combination with multivitamins and potentially harmful steroids or anti-allergy medicines.

In the standardized patient (SP) encounter, appropriate treatment was recommended by only 13% for pneumonia and by none of the practitioners for diarrhea. Also, fewer questions were asked about disease severity than in the vignette interviews.

The know-do gap was greater for diarrhea as compared to pneumonia. ORS prescriptions were greater in the vignette interview as compared to the SP encounter (72.4% vs 17.4%), while potentially harmful medications for diarrhea were more often prescribed in the SP encounter (71.9% vs 20.9%) respectively.

Unqualified personnel as compared to those with qualifications were more likely to prescribe potentially harmful medications for diarrhea (odds ratio 5.1) and pneumonia (OR 2.19).

"Although medically qualified practitioners do less harm than their unqualified counterparts," most practitioners in rural areas are unqualified," the researchers point out.

"Understanding factors that lead to this large know-do gap is critical to reducing preventable deaths due to diarrhea," the researchers explain.

"There is unfortunately no single solution to bridge the gap," Dr. Mohanan felt. "It will have to be a mix of incentives, information, and regulation to ensure that providers do the best they can," he concluded.

This study was supported by the Bill and Melinda Gates Foundation. The authors report no disclosures.

SOURCE: http://bit.ly/1Aj1szr

JAMA Pediatr 2015.